Healthcare Provider Details

I. General information

NPI: 1518261312
Provider Name (Legal Business Name): KATHERINE CHANDLER WALLACE PMHCNS-BC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/07/2011
Last Update Date: 01/07/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1611 CAMBRIDGE ST
CAMBRIDGE MA
02138-4302
US

IV. Provider business mailing address

50 HALL ST APT 1
JAMAICA PLAIN MA
02130-3220
US

V. Phone/Fax

Practice location:
  • Phone: 617-661-5515
  • Fax:
Mailing address:
  • Phone: 978-502-5804
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code364SP0809X
TaxonomyAdult Psychiatric/Mental Health Clinical Nurse Specialist
License NumberRN274714
License Number StateMA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: