Provider Demographics
NPI:1982269155
Name:WALLACE, DYLAN (LCSW, QCSW)
Entity type:Individual
Prefix:
First Name:DYLAN
Middle Name:
Last Name:WALLACE
Suffix:
Gender:M
Credentials:LCSW, QCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1469 N 1200 W
Mailing Address - Street 2:
Mailing Address - City:OREM
Mailing Address - State:UT
Mailing Address - Zip Code:84057-2449
Mailing Address - Country:US
Mailing Address - Phone:801-655-5450
Mailing Address - Fax:385-225-9327
Practice Address - Street 1:34 MAIN STREET EXT STE 104
Practice Address - Street 2:
Practice Address - City:PLYMOUTH
Practice Address - State:MA
Practice Address - Zip Code:02360-3375
Practice Address - Country:US
Practice Address - Phone:801-655-5450
Practice Address - Fax:385-225-9327
Is Sole Proprietor?:Yes
Enumeration Date:2019-05-03
Last Update Date:2024-12-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLSW152101041C0700X
AZLCSW-220601041C0700X
MALICSW1268611041C0700X
WALW612248501041C0700X
UT11338410-35011041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical