Healthcare Provider Details

I. General information

NPI: 1861758583
Provider Name (Legal Business Name): DR JOSEPH WALLACH PHD LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/06/2012
Last Update Date: 04/06/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4753 N BROADWAY ST SUITE 608
CHICAGO IL
60640-5266
US

IV. Provider business mailing address

2741 W GREENLEAF AVE
CHICAGO IL
60645-3013
US

V. Phone/Fax

Practice location:
  • Phone: 773-852-2400
  • Fax: 847-869-8116
Mailing address:
  • Phone: 773-852-2400
  • Fax: 847-869-8116

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code103TB0200X
TaxonomyCognitive & Behavioral Psychologist
License Number071007942
License Number StateIL
# 2
Primary TaxonomyN
Taxonomy Code103TH0004X
TaxonomyHealth Psychologist
License Number071007942
License Number StateIL
# 3
Primary TaxonomyY
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License Number071007942
License Number StateIL

VIII. Authorized Official

Name: DR. JOSEPH WALLACH
Title or Position: LICENSED CLINICAL PSYCHOLOGIST
Credential: PH.D.
Phone: 773-852-2400