Individual
JOEL WALLACE
Active
Sole proprietor
Yes
Provider details
NPI number
Gender
Man
Contact information
Practice address
4732 S 131ST ST, OMAHA, NE 68137-1822
(402) 697-3923
(402) 697-3924
Mailing address
4732 S 131ST ST, OMAHA, NE 68137-1822
(402) 697-3923
(402) 697-3924
Taxonomy
Speciality
Code
Description
License number
State
104100000X
Social Worker
Primary
2519
NE
Other
Other identifiers
Code
Description
Identifier
Issuer
State
05
—
47082303526
—
NE
Enumeration date
08/03/2012
Last updated
08/03/2012
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