Most Relevant Information
Provider Data
| NPI Number: | 1003388455 |
| Provider Name: | BETHANY WALLACE LCSW |
| Entity Type: | Individual |
| Taxonomy Code: | 1041C0700X |
| Specialty: | Social Worker |
| License Number: | 61687 |
Most Important Dates
| Enumeration Date: | 12/26/2018 |
| Last Updated: | 12/26/2018 |
Provider Practice Location
4686 BRISTOL TRACE TRL
FORT WORTH
TX
762446947
Practice Location Phone/Fax
| Phone: | 8177051586 |
| Fax: |
Provider Mailing Location
230 LACE LN
BURLESON
TX
760286736
Provider Mailing Phone/Fax
| Phone: | 8177391788 |
| Fax: |