Healthcare Provider Details

I. General information

NPI: 1932043957
Provider Name (Legal Business Name): LORETTA WALLACE
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/18/2026
Last Update Date: 04/18/2026
Certification Date: 04/18/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

60 E 112TH ST APT 402
NEW YORK NY
10029-0314
US

IV. Provider business mailing address

60 E 112TH ST APT 402
NEW YORK NY
10029-0314
US

V. Phone/Fax

Practice location:
  • Phone: 646-245-7639
  • Fax:
Mailing address:
  • Phone: 646-245-7639
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number41880
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: