MEDICARE: DR. RANDALL KENT WALLACE PSY.D.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	103TC0700X	Clinical Psychologist	2544	CT

General Provider Information

NPI Number	:	1891049003
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. RANDALL KENT WALLACE PSY.D.

Provider Business Mailing Address
First Line	:	36 RUSS ST
Second Line	:
City	:	HARTFORD
State	:	CT
Zip	:	06106-1520
Country	:	US
Telephone Number	:	860-466-9411
Fax Number	:

Provider Business Practice Location Address
First Line	:	36 RUSS ST
Second Line	:
City	:	HARTFORD
State	:	CT
Zip	:	06106-1520
Country	:	US
Telephone Number	:	860-466-9411
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	11/09/2012
Last Update Date	:	11/09/2016

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