Provider Demographics
NPI:1528107471
Name:WALLACE, HEIDI ALLISON WILKEN (LCSW)
Entity type:Individual
Prefix:
First Name:HEIDI
Middle Name:ALLISON WILKEN
Last Name:WALLACE
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:HEIDI
Other - Middle Name:ALLISON
Other - Last Name:WILKEN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:LCSW
Mailing Address - Street 1:27566 1375 EAST ST
Mailing Address - Street 2:
Mailing Address - City:WALNUT
Mailing Address - State:IL
Mailing Address - Zip Code:61376-9528
Mailing Address - Country:US
Mailing Address - Phone:815-383-7277
Mailing Address - Fax:815-379-2184
Practice Address - Street 1:27566 1375 EAST ST
Practice Address - Street 2:
Practice Address - City:WALNUT
Practice Address - State:IL
Practice Address - Zip Code:61376-9528
Practice Address - Country:US
Practice Address - Phone:815-383-7277
Practice Address - Fax:815-379-2184
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-06
Last Update Date:2012-11-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL1490129471041C0700X
ILHW49060306P222Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No222Q00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersDevelopmental Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
ILHW49060306POtherEARLY INTERVENTION