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General NPI Number Information
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NPI Number | 1982269155
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Entity Type | Individual
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Provider Name | DYLAN WALLACE LCSW, QCSW
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Gender | Male
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Dates
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Enumeration Date | 05/03/2019
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Last Update Date | 12/30/2024
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Provider Practice Location Address
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Address Line | 34 MAIN STREET EXT STE 104
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City | PLYMOUTH
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State | MA
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Zip | 02360-3375
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Country | US
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Telephone | 801-655-5450
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Fax | 385-225-9327
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Provider Business Mailing Address
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Address Line | 1469 N 1200 W
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City | OREM
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State | UT
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Zip | 84057-2449
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Country | US
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Telephone | 801-655-5450
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Fax | 385-225-9327
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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 | SW15210
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License Number State | FL
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Taxonomy #2
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Taxonomy Code | 1041C0700X
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Taxonomy Name | Clinical Social Worker
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License Number | LCSW-22060
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License Number State | AZ
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Taxonomy #3
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Taxonomy Code | 1041C0700X
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Taxonomy Name | Clinical Social Worker
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License Number | LICSW126861
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License Number State | MA
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Taxonomy #4
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Taxonomy Code | 1041C0700X
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Taxonomy Name | Clinical Social Worker
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License Number | LW61224850
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License Number State | WA
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Taxonomy #5
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Taxonomy Code | 1041C0700X
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Taxonomy Name | Clinical Social Worker
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License Number | 11338410-3501
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License Number State | UT
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