Provider Demographics
NPI:1871327858
Name:WALLACE, ALAINA M (LICSW)
Entity type:Individual
Prefix:
First Name:ALAINA
Middle Name:M
Last Name:WALLACE
Suffix:
Gender:F
Credentials:LICSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3340 REPUBLIC AVE STE 110
Mailing Address - Street 2:
Mailing Address - City:MINNEAPOLIS
Mailing Address - State:MN
Mailing Address - Zip Code:55426-4156
Mailing Address - Country:US
Mailing Address - Phone:952-529-4474
Mailing Address - Fax:952-209-1511
Practice Address - Street 1:3340 REPUBLIC AVE STE 110
Practice Address - Street 2:
Practice Address - City:MINNEAPOLIS
Practice Address - State:MN
Practice Address - Zip Code:55426-4156
Practice Address - Country:US
Practice Address - Phone:952-529-4474
Practice Address - Fax:952-209-1511
Is Sole Proprietor?:No
Enumeration Date:2024-08-30
Last Update Date:2024-08-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN297981041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical