Provider Demographics
NPI:1962894485
Name:WALLACE-KEANE, CHULETE AURIELLE (LCSW)
Entity type:Individual
Prefix:MRS
First Name:CHULETE
Middle Name:AURIELLE
Last Name:WALLACE-KEANE
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3280 MITCHELL BLVD
Mailing Address - Street 2:
Mailing Address - City:MOODY AFB
Mailing Address - State:GA
Mailing Address - Zip Code:31699-1500
Mailing Address - Country:US
Mailing Address - Phone:229-257-3898
Mailing Address - Fax:
Practice Address - Street 1:3280 MITCHELL BLVD
Practice Address - Street 2:
Practice Address - City:MOODY AFB
Practice Address - State:GA
Practice Address - Zip Code:31699-1500
Practice Address - Country:US
Practice Address - Phone:229-257-2778
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-02-20
Last Update Date:2023-12-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
1041C0700X
NCC0109761041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical