Nicole M. Wallace, MSW, LCSW

Primary specialty

Clinical Social WorkerTaxonomy code 1041C0700X

License

084663 Issued in NY

Practice address

177 Main St Ste 206
Huntington, NY 11743-6917

Phone

(631) 380-3454

NPI assigned

Jul 15, 2011

Last updated

Mar 17, 2018By the provider in NPPES

Sex

Female

Sole proprietor

No

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

Specialties & licenses 2

Addresses

Medicare fee-for-service enrollment

Not listed in the public Medicare enrollment file

Opted out of Medicare

Yes, effective Sep 11, 2023 through Sep 11, 2027

Medicare enrollment (NPD)

Not enrolled

State licenses

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

{
    "created_epoch": "1310688000000",
    "enumeration_type": "NPI-1",
    "last_updated_epoch": "1521244800000",
    "number": "1275821993",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "177 MAIN ST STE 206",
            "city": "HUNTINGTON",
            "state": "NY",
            "postal_code": "117436917"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "177 MAIN ST STE 206",
            "city": "HUNTINGTON",
            "state": "NY",
            "postal_code": "117436917",
            "telephone_number": "631-380-3454"
        }
    ],
    "practiceLocations": [
        {
            "address_1": "180 Livingston St",
            "address_2": "Suite 303",
            "address_purpose": "LOCATION",
            "city": "Brooklyn",
            "state": "NY",
            "postal_code": "112015861",
            "country_code": "US",
            "telephone_number": "347-328-8110",
            "country_name": "United States",
            "address_type": "DOM"
        }
    ],
    "basic": {
        "last_name": "WALLACE",
        "first_name": "NICOLE",
        "middle_name": "M.",
        "credential": "MSW, LCSW",
        "sole_proprietor": "NO",
        "sex": "F",
        "enumeration_date": "2011-07-15",
        "last_updated": "2018-03-17",
        "status": "A"
    },
    "taxonomies": [
        {
            "code": "104100000X",
            "taxonomy_group": "",
            "desc": "Social Worker",
            "state": "NY",
            "license": "084063",
            "primary": false
        },
        {
            "code": "1041C0700X",
            "taxonomy_group": "",
            "desc": "Social Worker, Clinical",
            "state": "NY",
            "license": "084663",
            "primary": true
        }
    ],
    "identifiers": [],
    "endpoints": [],
    "other_names": []
}

• Elaine M Walden, LCSW
• Elizabeth A Waldes, PA-C
• Walgreen Co (Rite Aid)
• William Alfred Walker, D.M.D., PH.D.
• Julia Brooks Wallace
• Allison Rohrecker Wallice, SPEECH PATHOLOGIST
• Eileen Walsh, ANP
• Kenneth A Walsh, M.D.
• Senaye Walters, LPN
• George L. Wang, M.D.

• Clinical Social Worker in Huntington, NY
• Providers in Huntington, NY by specialty
• Clinical Social Worker in New York

• NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Mar 17, 2018; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
• Medicare enrollment (CMS PECOS): enrollments, PAC IDs and benefit reassignments; Opt Out Affidavits.
• National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.

Verify at the official NPI Registry.