Provider Demographics
NPI:1043759053
Name:WALLACE, CARA (PSYD)
Entity Type:Individual
Prefix:
First Name:CARA
Middle Name:
Last Name:WALLACE
Suffix:
Gender:F
Credentials:PSYD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:76 NEW BRITAIN AVE
Mailing Address - Street 2:
Mailing Address - City:HARTFORD
Mailing Address - State:CT
Mailing Address - Zip Code:06106-3305
Mailing Address - Country:US
Mailing Address - Phone:860-547-0970
Mailing Address - Fax:
Practice Address - Street 1:76 NEW BRITAIN AVE
Practice Address - Street 2:
Practice Address - City:HARTFORD
Practice Address - State:CT
Practice Address - Zip Code:06106-3305
Practice Address - Country:US
Practice Address - Phone:860-547-0970
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-02-23
Last Update Date:2020-07-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT3947103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical