Healthcare Provider Details

I. General information

NPI: 1679314835
Provider Name (Legal Business Name): ADAM SCOTT WALLACH
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/03/2024
Last Update Date: 06/03/2024
Certification Date: 06/03/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

255 15TH ST
BROOKLYN NY
11215-4988
US

IV. Provider business mailing address

681 GRANDVIEW AVE APT 2
RIDGEWOOD NY
11385-2421
US

V. Phone/Fax

Practice location:
  • Phone: 718-788-5101
  • Fax:
Mailing address:
  • Phone: 321-408-9350
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: