Healthcare Provider Details

I. General information

NPI: 1679483820
Provider Name (Legal Business Name): DR. CARLY ROSEMARY FRANCES WALLACE
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: CARLY ROSEMARY FRANCES BARRY

II. Dates (important events)

Enumeration Date: 09/10/2026
Last Update Date: 09/10/2026
Certification Date: 09/10/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1919 W NORTH AVE STE 200
MILWAUKEE WI
53205-1101
US

IV. Provider business mailing address

W236S7800 WESTWOOD DR
BIG BEND WI
53103-9408
US

V. Phone/Fax

Practice location:
  • Phone: 414-257-7610
  • Fax:
Mailing address:
  • Phone: 414-257-7610
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103T00000X
TaxonomyPsychologist
License Number4133-57
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: