Healthcare Provider Details

I. General information

NPI: 1487169215
Provider Name (Legal Business Name): SETH WALLACE LMSW
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/01/2017
Last Update Date: 12/01/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5 SCIENCE PARK
NEW HAVEN CT
06511-1966
US

IV. Provider business mailing address

25 LYON ST
NEW HAVEN CT
06511-4925
US

V. Phone/Fax

Practice location:
  • Phone: 203-777-8648
  • Fax:
Mailing address:
  • Phone: 617-650-4988
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number4020
License Number StateCT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: