Provider Demographics
NPI:1407952054
Name:WALLACH, JEFFREY MICHAEL (LCSW-R)
Entity Type:Individual
Prefix:MR
First Name:JEFFREY
Middle Name:MICHAEL
Last Name:WALLACH
Suffix:
Gender:M
Credentials:LCSW-R
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Mailing Address - Street 1:1670 E 17TH ST # 78
Mailing Address - Street 2:INTERBOROUGH DEVELOPMENTAL AND CONSULTATION CENTER
Mailing Address - City:BROOKLYN
Mailing Address - State:NY
Mailing Address - Zip Code:11229-1258
Mailing Address - Country:US
Mailing Address - Phone:917-502-0762
Mailing Address - Fax:718-245-2517
Practice Address - Street 1:1670 E 17TH ST # 78
Practice Address - Street 2:INTERBOROUGH DEVELOPMENTAL AND CONSULTATION CENTER
Practice Address - City:BROOKLYN
Practice Address - State:NY
Practice Address - Zip Code:11229-1258
Practice Address - Country:US
Practice Address - Phone:917-502-0762
Practice Address - Fax:718-245-2517
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-14
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
NYR 023720-11041C0700X
NY023720-11041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical