Healthcare Provider Details

I. General information

NPI: 1255661310
Provider Name (Legal Business Name): ROBIN J WALLACE LCSW-R
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/12/2010
Last Update Date: 07/31/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

48 BURD ST SUITE 108
NYACK NY
10960-3226
US

IV. Provider business mailing address

48 BURD ST SUITE 108
NYACK NY
10960-3226
US

V. Phone/Fax

Practice location:
  • Phone: 845-729-1855
  • Fax:
Mailing address:
  • Phone: 845-729-1855
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License NumberR-071750-1
License Number StateNY

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: