Individual
MISS BETHANY WALLACE
Active
Sole proprietor
No
Provider details
NPI number
Gender
F
Credential
LCSW
Contact information
Practice address
4686 BRISTOL TRACE TRL, FORT WORTH, TX 76244-6947
(817) 705-1586
Mailing address
230 LACE LN, BURLESON, TX 76028-6736
(817) 739-1788
Taxonomy
Speciality
Code
Description
License number
State
1041C0700X
Clinical Social Worker
Primary
61687
TX
Other
Enumeration date
12/26/2018
Last updated
12/26/2018
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