Healthcare Provider Details

I. General information

NPI: 1710780507
Provider Name (Legal Business Name): JOSHUA WALLACE BS, MA
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/28/2025
Last Update Date: 03/28/2025
Certification Date: 03/28/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9007 WASHINGTON ST NE
ALBUQUERQUE NM
87113-2722
US

IV. Provider business mailing address

9007 WASHINGTON ST NE
ALBUQUERQUE NM
87113-2722
US

V. Phone/Fax

Practice location:
  • Phone: 505-699-8531
  • Fax:
Mailing address:
  • Phone: 505-699-8531
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: