MEDICARE: MS. DIANE WALLACH MSW, LMSW

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	104100000X	Social Worker	046968-1	NY

General Provider Information

NPI Number	:	1265746234
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MS. DIANE WALLACH MSW, LMSW

Provider Business Mailing Address
First Line	:	5800 ARLINGTON AVE APT 10B
Second Line	:
City	:	BRONX
State	:	NY
Zip	:	10471-1412
Country	:	US
Telephone Number	:	914-450-4066
Fax Number	:

Provider Business Practice Location Address
First Line	:	5800 ARLINGTON AVE APT 10B
Second Line	:
City	:	BRONX
State	:	NY
Zip	:	10471-1412
Country	:	US
Telephone Number	:	914-450-4066
Fax Number	:

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

Provider Enumeration Date	:	08/02/2010
Last Update Date	:	08/02/2010

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