MEDICARE: DR. DANIEL WALLACE DSW

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	104100000X	Social Worker	150.106556	IL

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1841771292
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. DANIEL WALLACE DSW

Provider Business Mailing Address
First Line	:	22997 KRISTINE LN
Second Line	:
City	:	RICHTON PARK
State	:	IL
Zip	:	60471-1273
Country	:	US
Telephone Number	:	708-925-7022
Fax Number	:

Provider Business Practice Location Address
First Line	:	22997 KRISTINE LN
Second Line	:
City	:	RICHTON PARK
State	:	IL
Zip	:	60471-1273
Country	:	US
Telephone Number	:	708-925-7022
Fax Number	:

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

Provider Enumeration Date	:	08/23/2018
Last Update Date	:	01/30/2024

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