MEDICARE: MR. JEFFREY MICHAEL WALLACH L.C.S.W.-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 023720-1	NY
2	1041C0700X	Clinical Social Worker	023720-1	NY

General Provider Information

NPI Number	:	1407952054
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MR. JEFFREY MICHAEL WALLACH L.C.S.W.-R.

Provider Business Mailing Address
First Line	:	1670 E 17TH ST # 78
Second Line	:	INTERBOROUGH DEVELOPMENTAL AND CONSULTATION CENTER
City	:	BROOKLYN
State	:	NY
Zip	:	11229-1258
Country	:	US
Telephone Number	:	917-502-0762
Fax Number	:	718-245-2517

Provider Business Practice Location Address
First Line	:	1670 E 17TH ST # 78
Second Line	:	INTERBOROUGH DEVELOPMENTAL AND CONSULTATION CENTER
City	:	BROOKLYN
State	:	NY
Zip	:	11229-1258
Country	:	US
Telephone Number	:	917-502-0762
Fax Number	:	718-245-2517

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

Provider Enumeration Date	:	09/14/2006
Last Update Date	:	07/08/2007

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