Healthcare Provider Details

I. General information

NPI: 1265117543
Provider Name (Legal Business Name): LAUREN CATHERINE WALLACE PHD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/15/2023
Last Update Date: 03/04/2026
Certification Date: 03/04/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

12 2ND ST
HACKENSACK NJ
07601-2009
US

IV. Provider business mailing address

12 2ND ST
HACKENSACK NJ
07601-2009
US

V. Phone/Fax

Practice location:
  • Phone: 551-996-8186
  • Fax:
Mailing address:
  • Phone: 551-996-8186
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License Number35SI00801300
License Number StateNJ
# 2
Primary TaxonomyN
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License Number027983
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: