Provider Demographics
NPI:1528667060
Name:WALLACE, DUSTIN WADE (LCSW)
Entity type:Individual
Prefix:MR
First Name:DUSTIN
Middle Name:WADE
Last Name:WALLACE
Suffix:
Gender:M
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4619 W SAGUARO DR
Mailing Address - Street 2:
Mailing Address - City:GLENDALE
Mailing Address - State:AZ
Mailing Address - Zip Code:85304-4424
Mailing Address - Country:US
Mailing Address - Phone:602-999-3355
Mailing Address - Fax:
Practice Address - Street 1:4619 W SAGUARO DR
Practice Address - Street 2:
Practice Address - City:GLENDALE
Practice Address - State:AZ
Practice Address - Zip Code:85304-4424
Practice Address - Country:US
Practice Address - Phone:602-999-3355
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-10-24
Last Update Date:2023-08-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LCSW-217561041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical