Provider Demographics
NPI:1215243043
Name:WALLACE, REBECCA ANN (MSW)
Entity type:Individual
Prefix:MRS
First Name:REBECCA
Middle Name:ANN
Last Name:WALLACE
Suffix:
Gender:F
Credentials:MSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4950 MEMORIAL DR
Mailing Address - Street 2:
Mailing Address - City:HOUSTON
Mailing Address - State:TX
Mailing Address - Zip Code:77007-7440
Mailing Address - Country:US
Mailing Address - Phone:713-802-7714
Mailing Address - Fax:
Practice Address - Street 1:4950 MEMORIAL DR
Practice Address - Street 2:
Practice Address - City:HOUSTON
Practice Address - State:TX
Practice Address - Zip Code:77007-7440
Practice Address - Country:US
Practice Address - Phone:713-802-7714
Practice Address - Fax:713-802-6230
Is Sole Proprietor?:No
Enumeration Date:2010-08-31
Last Update Date:2015-06-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
104100000X
TX605161041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No104100000XBehavioral Health & Social Service ProvidersSocial Worker