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General NPI Number Information
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NPI Number | 1649696394
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Entity Type | Individual
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Provider Name | BROOKE WALLACE LCSW
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Gender | Female
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Dates
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Enumeration Date | 03/05/2014
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Last Update Date | 06/17/2024
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Provider Practice Location Address
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Address Line | 1521 MERRILL DRIVE SUITE D220
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City | LITTLE ROCK
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State | AR
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Zip | 72211-1654
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Country | US
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Telephone | 501-660-6893
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Fax | 501-954-7798
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Provider Business Mailing Address
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Address Line | P.O. BOX 251970
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City | LITTLE ROCK
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State | AR
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Zip | 72225-1970
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Country | US
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Telephone | 501-666-8686
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Fax | 501-660-6830
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 1041C0700X
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Taxonomy Name | Clinical Social Worker
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License Number | 5568-C
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License Number State | AR
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