Provider Demographics
NPI:1093968828
Name:WALLACH, DANA K (LMFT)
Entity Type:Individual
Prefix:
First Name:DANA
Middle Name:K
Last Name:WALLACH
Suffix:
Gender:F
Credentials:LMFT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:588 MAIN ST
Mailing Address - Street 2:
Mailing Address - City:SHREWSBURY
Mailing Address - State:MA
Mailing Address - Zip Code:01545-2920
Mailing Address - Country:US
Mailing Address - Phone:310-880-8889
Mailing Address - Fax:
Practice Address - Street 1:588 MAIN ST
Practice Address - Street 2:
Practice Address - City:SHREWSBURY
Practice Address - State:MA
Practice Address - Zip Code:01545-2920
Practice Address - Country:US
Practice Address - Phone:310-880-8889
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-10-24
Last Update Date:2010-05-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA45024106H00000X
MA1337106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA45024OtherLMFT
MA1337OtherLMFT LICENSE