MEDICARE: MS. ROBIN J WALLACE LCSW-R

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	1041C0700X	Clinical Social Worker	R-071750-1	NY

General Provider Information

NPI Number	:	1255661310
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MS. ROBIN J WALLACE LCSW-R

Provider Business Mailing Address
First Line	:	48 BURD ST
Second Line	:	SUITE 108
City	:	NYACK
State	:	NY
Zip	:	10960-3226
Country	:	US
Telephone Number	:	845-729-1855
Fax Number	:

Provider Business Practice Location Address
First Line	:	48 BURD ST
Second Line	:	SUITE 108
City	:	NYACK
State	:	NY
Zip	:	10960-3226
Country	:	US
Telephone Number	:	845-729-1855
Fax Number	:

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

Provider Enumeration Date	:	01/12/2010
Last Update Date	:	07/31/2014

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