=====================================================
General NPI Number Information
=====================================================
NPI Number | 1710368642
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | JUDY C WALLACE M.S.,SP.ED,LIT
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 06/16/2015
-----------------------------------------------------
Last Update Date | 04/12/2016
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 4242 RIDGE LEA RD
-----------------------------------------------------
City | AMHERST
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 14226-1051
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 716-819-2400
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 535 LEIN RD
-----------------------------------------------------
City | WEST SENECA
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 14224-2443
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 716-674-3062
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 174400000X
-----------------------------------------------------
Taxonomy Name | Specialist
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------