Provider Demographics
NPI:1255661310
Name:WALLACE, ROBIN J (LCSW-R)
Entity Type:Individual
Prefix:MS
First Name:ROBIN
Middle Name:J
Last Name:WALLACE
Suffix:
Gender:F
Credentials:LCSW-R
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:48 BURD ST
Mailing Address - Street 2:SUITE 108
Mailing Address - City:NYACK
Mailing Address - State:NY
Mailing Address - Zip Code:10960-3226
Mailing Address - Country:US
Mailing Address - Phone:845-729-1855
Mailing Address - Fax:
Practice Address - Street 1:48 BURD ST
Practice Address - Street 2:SUITE 108
Practice Address - City:NYACK
Practice Address - State:NY
Practice Address - Zip Code:10960-3226
Practice Address - Country:US
Practice Address - Phone:845-729-1855
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-01-12
Last Update Date:2014-07-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYR-071750-11041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical