MEDICARE: DIANA WALLACE LCSW

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	005144	CT
2	1041C0700X	Clinical Social Worker	3632	KY

General Provider Information

NPI Number	:	1336145432
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DIANA WALLACE LCSW

Provider Business Mailing Address
First Line	:	1 NUNN DR
Second Line	:	UNIVERSITY CENTER, SUITE 440
City	:	NEWPORT
State	:	KY
Zip	:	41099-0002
Country	:	US
Telephone Number	:	859-572-5650
Fax Number	:	859-572-5615

Provider Business Practice Location Address
First Line	:	1 NUNN DR
Second Line	:	UNIVERSITY CENTER, SUITE 440
City	:	NEWPORT
State	:	KY
Zip	:	41099-0002
Country	:	US
Telephone Number	:	859-572-5650
Fax Number	:	859-572-5615

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

Provider Enumeration Date	:	06/23/2005
Last Update Date	:	06/12/2012

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Directions to “ DIANA WALLACE LCSW” Practice Location

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