Provider Demographics
NPI:1528491529
Name:WALLACE, SHERRIE K (MSW, LCSW)
Entity type:Individual
Prefix:
First Name:SHERRIE
Middle Name:K
Last Name:WALLACE
Suffix:
Gender:F
Credentials:MSW, LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:422 S SOUTHGATE DR
Mailing Address - Street 2:
Mailing Address - City:NIXA
Mailing Address - State:MO
Mailing Address - Zip Code:65714-9004
Mailing Address - Country:US
Mailing Address - Phone:417-726-9573
Mailing Address - Fax:660-243-4407
Practice Address - Street 1:4650 S NATIONAL AVE STE C1
Practice Address - Street 2:
Practice Address - City:SPRINGFIELD
Practice Address - State:MO
Practice Address - Zip Code:65810-2895
Practice Address - Country:US
Practice Address - Phone:660-243-4363
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-08-13
Last Update Date:2024-07-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT6731308-35011041C0700X
MO20170017381041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO490044558Medicaid