Active NPI
Kristen Shae Wallace
- Social Worker
- Forest Hills, NY
National Provider Identifier
1104263896
On this page
Key facts
NPPES NPI Registry- Primary specialty
- Social Worker
- License
- 091021
- Practice address
- 7261 113TH St Apt 2R
Forest Hills, NY 11375-5601 - Phone
- (718) 679-3595
- NPI assigned
- Jun 4, 2013
- Sex
- Female
- Sole proprietor
- Yes
NPPES NPI Registry
Registry information is reported by the provider to CMS and is not verified. About this source
Specialties & licenses 1
| Specialty (taxonomy) | Code | License | State | Primary |
|---|---|---|---|---|
| Social Worker | 104100000X | 091021 | NY | Primary |
Addresses
Primary practice location
7261 113TH St Apt 2R
Forest Hills, NY 11375-5601
Mailing address
7261 113TH St Apt 2R
Forest Hills, NY 11375-5601
Phone (718) 679-3595
Medicare participation
Medicare enrollment files- Medicare fee-for-service enrollment
- Not listed in the public Medicare enrollment file
National Provider Directory
National Provider Directory- Medicare enrollment (NPD)
- Not enrolled
State licenses
| License | State | Type | Specialty |
|---|---|---|---|
| 091021 | NY | MD | Clinical Social Worker |
NPI Registry JSON
The complete NPPES record for this NPI in the NPI Registry API format.
{
"created_epoch": "1370304000000",
"enumeration_type": "NPI-1",
"last_updated_epoch": "1714694400000",
"number": "1104263896",
"addresses": [
{
"country_code": "US",
"country_name": "United States",
"address_purpose": "MAILING",
"address_type": "DOM",
"address_1": "7261 113TH ST APT 2R",
"city": "FOREST HILLS",
"state": "NY",
"postal_code": "113755601",
"telephone_number": "718-679-3595"
},
{
"country_code": "US",
"country_name": "United States",
"address_purpose": "LOCATION",
"address_type": "DOM",
"address_1": "7261 113TH ST APT 2R",
"city": "FOREST HILLS",
"state": "NY",
"postal_code": "113755601",
"telephone_number": "718-679-3595"
}
],
"practiceLocations": [],
"basic": {
"last_name": "WALLACE",
"first_name": "KRISTEN",
"middle_name": "SHAE",
"name_prefix": "Ms.",
"sole_proprietor": "YES",
"sex": "F",
"enumeration_date": "2013-06-04",
"last_updated": "2024-05-03",
"certification_date": "2024-05-03",
"status": "A"
},
"taxonomies": [
{
"code": "104100000X",
"taxonomy_group": "",
"desc": "Social Worker",
"state": "NY",
"license": "091021",
"primary": true
}
],
"identifiers": [],
"endpoints": [],
"other_names": []
}Other providers in Forest Hills, NY
Sources for this page
- NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on May 3, 2024; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
- National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.