Provider Demographics
NPI:1346430386
Name:WALLACE, DAVID A (LCSW-R)
Entity Type:Individual
Prefix:MR
First Name:DAVID
Middle Name:A
Last Name:WALLACE
Suffix:
Gender:M
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 1:251 NEW KARNER RD
Mailing Address - Street 2:BOX 604
Mailing Address - City:ALBANY
Mailing Address - State:NY
Mailing Address - Zip Code:12205-4617
Mailing Address - Country:US
Mailing Address - Phone:518-248-4351
Mailing Address - Fax:
Practice Address - Street 1:251 NEW KARNER RD
Practice Address - Street 2:BOX 604
Practice Address - City:ALBANY
Practice Address - State:NY
Practice Address - Zip Code:12205-4617
Practice Address - Country:US
Practice Address - Phone:518-248-4351
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-07-26
Last Update Date:2008-05-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY07030411041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical