MEDICARE: ALLISON WALLACE MSW, MFT

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	1041C0700X	Clinical Social Worker	I.1600716	OH
2	1041C0700X	Clinical Social Worker	CSW005555	GA

General Provider Information

NPI Number	:	1023558103
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	ALLISON WALLACE MSW, MFT

Provider Business Mailing Address
First Line	:	2456 HEARTHSTEAD LN
Second Line	:
City	:	CINCINNATI
State	:	OH
Zip	:	45239-6616
Country	:	US
Telephone Number	:	404-798-1055
Fax Number	:

Provider Business Practice Location Address
First Line	:	2456 HEARTHSTEAD LN
Second Line	:
City	:	CINCINNATI
State	:	OH
Zip	:	45239-6616
Country	:	US
Telephone Number	:	404-798-1055
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	03/08/2017
Last Update Date	:	03/08/2017

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