MEDICARE: DR. AMIRA PARIS WALLACH PH.D.

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	103TC0700X	Clinical Psychologist	SIO1674	NJ
2	103TC0700X	Clinical Psychologist	35SI00167400	NJ

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1417004631
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. AMIRA PARIS WALLACH PH.D.

Provider Business Mailing Address
First Line	:	40 S HIGHWOOD AVE
Second Line	:
City	:	GLEN ROCK
State	:	NJ
Zip	:	07452-1402
Country	:	US
Telephone Number	:	201-652-6067
Fax Number	:

Provider Business Practice Location Address
First Line	:	40 S HIGHWOOD AVE
Second Line	:
City	:	GLEN ROCK
State	:	NJ
Zip	:	07452-1402
Country	:	US
Telephone Number	:	201-652-6067
Fax Number	:

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

Provider Enumeration Date	:	01/03/2007
Last Update Date	:	07/15/2020

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