Bethany Wallace, LCSW

Primary specialty

Clinical Social WorkerTaxonomy code 1041C0700X

License

61687 Issued in TX

Practice address

4686 Bristol Trace TRL
Fort Worth, TX 76244-6947

Phone

(817) 705-1586

NPI assigned

Dec 26, 2018

Sex

Female

Sole proprietor

No

Registry information is reported by the provider to CMS and is not verified. About this source

Specialties & licenses 1

Addresses

Medicare fee-for-service enrollment

Not listed in the public Medicare enrollment file

Medicare enrollment (NPD)

Not enrolled

State licenses

The complete NPPES record for this NPI in the NPI Registry API format.

{
    "created_epoch": "1545782400000",
    "enumeration_type": "NPI-1",
    "last_updated_epoch": "1545782400000",
    "number": "1003388455",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "230 LACE LN",
            "city": "BURLESON",
            "state": "TX",
            "postal_code": "760286736",
            "telephone_number": "817-739-1788"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "4686 BRISTOL TRACE TRL",
            "city": "FORT WORTH",
            "state": "TX",
            "postal_code": "762446947",
            "telephone_number": "817-705-1586"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "last_name": "WALLACE",
        "first_name": "BETHANY",
        "name_prefix": "Miss",
        "credential": "LCSW",
        "sole_proprietor": "NO",
        "sex": "F",
        "enumeration_date": "2018-12-26",
        "last_updated": "2018-12-26",
        "status": "A"
    },
    "taxonomies": [
        {
            "code": "1041C0700X",
            "taxonomy_group": "",
            "desc": "Social Worker, Clinical",
            "state": "TX",
            "license": "61687",
            "primary": true
        }
    ],
    "identifiers": [],
    "endpoints": [],
    "other_names": []
}

• Keaton Wall
• Krista Wall, SLP
• Allan M Wallace, O.D.
• Angela Webb Wallace, OTR
• Ashley Lynette Wallace, MSN, APRN, FNP-C,
• Cristy L Wallace, FNP
• Gabriel Wallace
• Paige Marie Wallace
• Rafaella Izar Wallace, ANP
• Rane Perry Wallace, MS, LPC, LCDC, SAP

• Clinical Social Worker in Fort Worth, TX
• Providers in Fort Worth, TX by specialty
• Clinical Social Worker in Texas

• NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Dec 26, 2018; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
• National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.

Verify at the official NPI Registry.