Dylan Wallace, LCSW, QCSW

Primary specialty

Clinical Social WorkerTaxonomy code 1041C0700X

License

LICSW126861 Issued in MA

Practice address

34 Main Street Ext Ste 104
Plymouth, MA 02360-3375

Phone

(801) 655-5450

Fax

(385) 225-9327

NPI assigned

May 3, 2019

Sex

Male

Sole proprietor

No

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

Specialties & licenses 5

Addresses

Other names 1

• Dylan Shane Wallace Other name

Medicare fee-for-service enrollment

Enrolled in MA, WA, UT, ID4 enrollments

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.

Enrollment records 4

Specialty

Clinical Social Worker

Education

Other, 2013

Medicare assignment

Accepts the Medicare-approved amount as payment in full

Group practices

Meadowbrook Counseling of Utah LLCGroup PAC ID 8729527213, 17 clinicians

Practice addresses (Care Compare)

Medicare enrollment (NPD)

Enrolled

State licenses

Practice roles

Locations

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.

• Meadowbrook Counseling of Utah LLC

  • Mental Health Counselor
  • Orem, UT
  • NPI 1225619737

  Clinical, UT

  Medicare reassignment Care Compare group NPD
• Meadowbrook Counseling of Idaho, LLC

  • Clinical Social Worker
  • Idaho Falls, ID
  • NPI 1023889839

  Clinical, ID

  Medicare reassignment NPD
• Meadowbrook Counseling of Washington, LLC

  • Clinical Social Worker
  • Bothell, WA
  • NPI 1467230284

  Clinical, WA

  Medicare reassignment NPD
• Meadowbrook Counseling of Massachusetts, LLC

  • Clinical Social Worker
  • Plymouth, MA
  • NPI 1689445488

  MA

  Medicare reassignment
• Meadowbrook Counseling of Arizona, LLC

  • Clinical Social Worker
  • Gilbert, AZ
  • NPI 1669251120

  Clinical

  NPD (past)
• Meadowbrook Counseling of Florida, LLC

  • Clinical Social Worker
  • Maitland, FL
  • NPI 1962266635

  Clinical

  NPD (past)
• Mountain View Family Eyecare PLLC

  • Optometrist
  • Heber City, UT
  • NPI 1801198247
  NPD (past)

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

{
    "created_epoch": "1556841600000",
    "enumeration_type": "NPI-1",
    "last_updated_epoch": "1775088000000",
    "number": "1982269155",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "1469 N 1200 W",
            "city": "OREM",
            "state": "UT",
            "postal_code": "840572449",
            "telephone_number": "801-655-5450",
            "fax_number": "385-225-9327"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "34 MAIN STREET EXT STE 104",
            "city": "PLYMOUTH",
            "state": "MA",
            "postal_code": "023603375",
            "telephone_number": "801-655-5450",
            "fax_number": "385-225-9327"
        }
    ],
    "practiceLocations": [
        {
            "address_1": "1469 N 1200 W",
            "address_purpose": "LOCATION",
            "city": "Orem",
            "state": "UT",
            "postal_code": "840572449",
            "country_code": "US",
            "telephone_number": "801-655-5450",
            "fax_number": "385-225-9327",
            "country_name": "United States",
            "address_type": "DOM"
        }
    ],
    "basic": {
        "last_name": "WALLACE",
        "first_name": "DYLAN",
        "credential": "LCSW, QCSW",
        "sole_proprietor": "NO",
        "sex": "M",
        "enumeration_date": "2019-05-03",
        "last_updated": "2026-04-02",
        "certification_date": "2026-04-02",
        "status": "A"
    },
    "taxonomies": [
        {
            "code": "1041C0700X",
            "taxonomy_group": "",
            "desc": "Social Worker, Clinical",
            "state": "WA",
            "license": "SWI.LW.61224850",
            "primary": false
        },
        {
            "code": "1041C0700X",
            "taxonomy_group": "",
            "desc": "Social Worker, Clinical",
            "state": "MA",
            "license": "LICSW126861",
            "primary": true
        },
        {
            "code": "1041C0700X",
            "taxonomy_group": "",
            "desc": "Social Worker, Clinical",
            "state": "FL",
            "license": "SW15210",
            "primary": false
        },
        {
            "code": "1041C0700X",
            "taxonomy_group": "",
            "desc": "Social Worker, Clinical",
            "state": "ID",
            "license": "3381901",
            "primary": false
        },
        {
            "code": "1041C0700X",
            "taxonomy_group": "",
            "desc": "Social Worker, Clinical",
            "state": "UT",
            "license": "11338410-3501",
            "primary": false
        }
    ],
    "identifiers": [],
    "endpoints": [],
    "other_names": [
        {
            "first_name": "DYLAN",
            "last_name": "WALLACE",
            "middle_name": "SHANE",
            "code": "5",
            "type": "Other Name"
        }
    ]
}

• Walgreen Co
• Walgreen Co
• Erica Walker
• George T. Walker, M.ED
• Cynthia Irene Wall, BCBA
• Joyce Ann Wallace, LMHC
• Natalie T Wallace
• Robin Wallace, M.ED
• Jacqulyn T Walorz
• Brittany Walsh, FNP

• Clinical Social Worker in Plymouth, MA
• Providers in Plymouth, MA by specialty
• Clinical Social Worker in Massachusetts

• NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Apr 2, 2026; 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.