Kristin Wallace

Primary specialty

Clinical Social WorkerTaxonomy code 1041C0700X

License

M8300 Issued in MS

Practice address

940 Ebenezer Blvd
Madison, MS 39110-6002

Phone

(601) 790-0583

NPI assigned

Aug 5, 2020

Sex

Female

Sole proprietor

Yes

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

Specialties & licenses 1

Addresses

Electronic endpoints 1

Medicare fee-for-service enrollment

Not listed in the public Medicare enrollment file

Medicare enrollment (NPD)

Not enrolled

State licenses

Practice roles

Organizations this provider is connected to: Medicare benefit reassignments (the organization bills Medicare for this provider’s services), Care Compare group memberships and National Provider Directory roles.

• Lifeworks Counseling

  • Community/Behavioral Health Agency
  • Madison, MS
  • NPI 1124471412
  NPD (past)

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

{
    "created_epoch": "1596585600000",
    "enumeration_type": "NPI-1",
    "last_updated_epoch": "1596585600000",
    "number": "1154931129",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "437 PIN OAK DR",
            "city": "MADISON",
            "state": "MS",
            "postal_code": "391109365"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "940 EBENEZER BLVD",
            "city": "MADISON",
            "state": "MS",
            "postal_code": "391106002",
            "telephone_number": "601-790-0583"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "last_name": "WALLACE",
        "first_name": "KRISTIN",
        "sole_proprietor": "YES",
        "sex": "F",
        "enumeration_date": "2020-08-05",
        "last_updated": "2020-08-05",
        "certification_date": "2020-08-05",
        "status": "A"
    },
    "taxonomies": [
        {
            "code": "1041C0700X",
            "taxonomy_group": "",
            "desc": "Social Worker, Clinical",
            "state": "MS",
            "license": "M8300",
            "primary": true
        }
    ],
    "identifiers": [],
    "endpoints": [
        {
            "endpointType": "DIRECT",
            "endpointTypeDescription": "Direct Messaging Address",
            "endpoint": "admin@lifeworksms.com",
            "affiliation": "N",
            "address_1": "940 Ebenezer Blvd",
            "city": "Madison",
            "state": "MS",
            "country_code": "US",
            "postal_code": "391106002",
            "country_name": "United States",
            "address_type": "DOM"
        }
    ],
    "other_names": []
}

• Walgreen Co
• Micah R. Walker, M.D.
• Patrick Wade Walker, RPH
• Sarah Beth Walker, MA, LPC
• Tara T Walker, PA
• Zilin Wang, M.D.
• Elizabeth Warman, RPH
• Cathrine Warren
• Kathy Ward Warwick, RD/CDE
• Tina Washington-Anderson, LPC

• Clinical Social Worker in Madison, MS
• Providers in Madison, MS by specialty
• Clinical Social Worker in Mississippi

• NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Aug 5, 2020; 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.