Provider Demographics
NPI:1528431657
Name:WALLACE, YASHAUNA (LISW)
Entity type:Individual
Prefix:
First Name:YASHAUNA
Middle Name:
Last Name:WALLACE
Suffix:
Gender:F
Credentials:LISW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8354 PRINCETON GLENDALE RD STE 102
Mailing Address - Street 2:
Mailing Address - City:WEST CHESTER
Mailing Address - State:OH
Mailing Address - Zip Code:45069-2130
Mailing Address - Country:US
Mailing Address - Phone:513-813-1908
Mailing Address - Fax:
Practice Address - Street 1:6809 MAIN ST UNIT 953
Practice Address - Street 2:
Practice Address - City:CINCINNATI
Practice Address - State:OH
Practice Address - Zip Code:45244-3470
Practice Address - Country:US
Practice Address - Phone:513-813-1908
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-11-11
Last Update Date:2024-07-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHI.18013351041C0700X
NCC0144211041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical