MEDICARE: MISS CYNTHIA L WALLACE THERAPIST

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	101YM0800X	Mental Health Counselor
2	171M00000X	Case Manager/Care Coordinator

General Provider Information

NPI Number	:	1710264940
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MISS CYNTHIA L WALLACE THERAPIST

Provider Business Mailing Address
First Line	:	51 TREMONT TER
Second Line	:
City	:	IRVINGTON
State	:	NJ
Zip	:	07111-3709
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	358 SAINT MARKS PL
Second Line	:
City	:	STATEN ISLAND
State	:	NY
Zip	:	10301-2417
Country	:	US
Telephone Number	:	718-727-3303
Fax Number	:

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

Provider Enumeration Date	:	11/16/2011
Last Update Date	:	11/16/2011

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