Provider Demographics
NPI:1326777871
Name:WALLACE, NORAH SUZANNE
Entity Type:Individual
Prefix:DR
First Name:NORAH
Middle Name:SUZANNE
Last Name:WALLACE
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:138 W 25TH ST FL 11
Mailing Address - Street 2:
Mailing Address - City:NEW YORK
Mailing Address - State:NY
Mailing Address - Zip Code:10001-7405
Mailing Address - Country:US
Mailing Address - Phone:646-770-3518
Mailing Address - Fax:
Practice Address - Street 1:138 W 25TH ST FL 11
Practice Address - Street 2:
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10001-7405
Practice Address - Country:US
Practice Address - Phone:646-770-3518
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-06-09
Last Update Date:2024-02-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ35SI00732000103TC0700X
NYP113414103TC0700X
NY025328103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical