MEDICARE: DORIAN JAMES WALLACE MT-BC

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	225A00000X	Music Therapist	16406	NY

General Provider Information

NPI Number	:	1518797794
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DORIAN JAMES WALLACE MT-BC

Provider Business Mailing Address
First Line	:	1510 CARROLL ST APT 2A
Second Line	:
City	:	BROOKLYN
State	:	NY
Zip	:	11213-4527
Country	:	US
Telephone Number	:	330-592-5264
Fax Number	:

Provider Business Practice Location Address
First Line	:	1510 CARROLL ST APT 2A
Second Line	:
City	:	BROOKLYN
State	:	NY
Zip	:	11213-4527
Country	:	US
Telephone Number	:	330-592-5264
Fax Number	:

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

Provider Enumeration Date	:	08/03/2024
Last Update Date	:	08/03/2024

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