Evan C Wallace, LMSW

Primary specialty

Clinical Social WorkerTaxonomy code 1041C0700X

License

2024022765 Issued in MO

Practice address

154 Forrest Dr
Hannibal, MO 63401-5511

Phone

(573) 221-2120

Fax

(573) 221-4380

NPI assigned

Jul 2, 2024

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

Eligible to order & refer

• Part B services: Yes
• Medical equipment: Yes
• Home health: No
• Power mobility devices: No
• Hospice: No

Green means eligible to order or refer.

Specialty

Clinical Social Worker

Education

Other, 2024

Medicare assignment

May accept Medicare assignment

Practice addresses (Care Compare)

Medicare enrollment (NPD)

Enrolled

State licenses

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

{
    "created_epoch": "1719878400000",
    "enumeration_type": "NPI-1",
    "last_updated_epoch": "1719878400000",
    "number": "1770329583",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "154 FORREST DR",
            "city": "HANNIBAL",
            "state": "MO",
            "postal_code": "634015511",
            "telephone_number": "573-221-2120",
            "fax_number": "573-221-4380"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "154 FORREST DR",
            "city": "HANNIBAL",
            "state": "MO",
            "postal_code": "634015511",
            "telephone_number": "573-221-2120",
            "fax_number": "573-221-4380"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "last_name": "WALLACE",
        "first_name": "EVAN",
        "middle_name": "C",
        "credential": "LMSW",
        "sole_proprietor": "YES",
        "sex": "M",
        "enumeration_date": "2024-07-02",
        "last_updated": "2024-07-02",
        "certification_date": "2024-07-02",
        "status": "A"
    },
    "taxonomies": [
        {
            "code": "1041C0700X",
            "taxonomy_group": "",
            "desc": "Social Worker, Clinical",
            "state": "MO",
            "license": "2024022765",
            "primary": true
        }
    ],
    "identifiers": [],
    "endpoints": [],
    "other_names": []
}

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• All providers in Hannibal, MO
• Clinical Social Worker in Missouri

• NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Jul 2, 2024; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
• Medicare enrollment (CMS PECOS): enrollments, PAC IDs and benefit reassignments; Order and Referring.
• Medicare Care Compare (CMS): clinician profile, group practices, facility affiliations, MIPS scores and star ratings.
• National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.

Verify at the official NPI Registry.