Ty Lamar Wallace, MSW

Primary specialty

Clinical Social WorkerTaxonomy code 1041C0700X

License

149-010121 Issued in IL

Practice address

4904 Bowls Bottom Rd
Pinckneyville, IL 62274-2453

Phone

(618) 926-6050

NPI assigned

Jul 7, 2017

Sex

Male

Sole proprietor

Yes

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)

Enrolled

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

{
    "created_epoch": "1499385600000",
    "enumeration_type": "NPI-1",
    "last_updated_epoch": "1658361600000",
    "number": "1295257624",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "4904 BOWLS BOTTOM RD",
            "city": "PINCKNEYVILLE",
            "state": "IL",
            "postal_code": "622742453",
            "telephone_number": "618-926-6050"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "4904 BOWLS BOTTOM RD",
            "city": "PINCKNEYVILLE",
            "state": "IL",
            "postal_code": "622742453",
            "telephone_number": "618-926-6050"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "last_name": "WALLACE",
        "first_name": "TY",
        "middle_name": "LAMAR",
        "credential": "MSW",
        "sole_proprietor": "YES",
        "sex": "M",
        "enumeration_date": "2017-07-07",
        "last_updated": "2022-07-21",
        "status": "A"
    },
    "taxonomies": [
        {
            "code": "1041C0700X",
            "taxonomy_group": "",
            "desc": "Social Worker, Clinical",
            "state": "IL",
            "license": "149-010121",
            "primary": true
        }
    ],
    "identifiers": [],
    "endpoints": [],
    "other_names": []
}

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• Clinical Social Worker in Pinckneyville, IL
• Providers in Pinckneyville, IL by specialty
• Clinical Social Worker in Illinois

• NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Jul 21, 2022; 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.