MEDICARE: ALISON D WALLACK M.S.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	235Z00000X	Speech-Language Pathologist	015449	NY

General Provider Information

NPI Number	:	1093967093
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	ALISON D WALLACK M.S.

Provider Business Mailing Address
First Line	:	404 E 88TH ST
Second Line	:	APT. 5F
City	:	NEW YORK
State	:	NY
Zip	:	10128-6613
Country	:	US
Telephone Number	:	917-751-3919
Fax Number	:

Provider Business Practice Location Address
First Line	:	404 E 88TH ST
Second Line	:	APT. 5F
City	:	NEW YORK
State	:	NY
Zip	:	10128-6613
Country	:	US
Telephone Number	:	917-751-3919
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	10/21/2008
Last Update Date	:	10/21/2008

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