Provider Demographics
NPI:1104971712
Name:WALLACE, KEITH V (LCSW)
Entity type:Individual
Prefix:MR
First Name:KEITH
Middle Name:V
Last Name:WALLACE
Suffix:
Gender:M
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:CHILDREN'S MEMORIAL HOSPITAL
Mailing Address - Street 2:2300 CHILDREN'S PLAZA, BOX 10
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60614
Mailing Address - Country:US
Mailing Address - Phone:773-975-8604
Mailing Address - Fax:
Practice Address - Street 1:CHILDREN'S MEMORIAL HOSPITAL
Practice Address - Street 2:2300 CHILDREN'S PLAZA, BOX 10
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60614
Practice Address - Country:US
Practice Address - Phone:773-975-8604
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-24
Last Update Date:2008-10-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL149-012034104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker