Healthcare Provider Details

I. General information

NPI: 1154622256
Provider Name (Legal Business Name): ABIGAIL WALLMAN
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/05/2010
Last Update Date: 10/13/2024
Certification Date: 10/13/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

30 MEADOWLARK RD
WEST SIMSBURY CT
06092-2418
US

IV. Provider business mailing address

30 MEADOWLARK RD
WEST SIMSBURY CT
06092-2418
US

V. Phone/Fax

Practice location:
  • Phone: 845-863-9011
  • Fax:
Mailing address:
  • Phone: 845-863-9011
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License Number4807
License Number StateCT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: