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General NPI Number Information
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NPI Number | 1992987754
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Entity Type | Individual
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Provider Name | BETHANY WALLACE LCSW
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Gender | Female
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Dates
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Enumeration Date | 12/03/2007
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Last Update Date | 06/02/2025
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Provider Practice Location Address
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Address Line | 2450 LANCASTER DR NE
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City | SALEM
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State | OR
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Zip | 97305-1130
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Country | US
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Telephone | 503-783-4004
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Fax |
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Provider Business Mailing Address
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Address Line | 3624 COMMERCIAL ST SE UNIT 4364
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City | SALEM
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State | OR
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Zip | 97302-6712
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Country | US
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Telephone | 503-783-4004
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Fax |
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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 | 5807
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License Number State | OR
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