Provider Demographics
NPI:1417004631
Name:WALLACH, AMIRA PARIS (PHD)
Entity Type:Individual
Prefix:DR
First Name:AMIRA
Middle Name:PARIS
Last Name:WALLACH
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:40 S HIGHWOOD AVE
Mailing Address - Street 2:
Mailing Address - City:GLEN ROCK
Mailing Address - State:NJ
Mailing Address - Zip Code:07452-1402
Mailing Address - Country:US
Mailing Address - Phone:201-652-6067
Mailing Address - Fax:
Practice Address - Street 1:40 S HIGHWOOD AVE
Practice Address - Street 2:
Practice Address - City:GLEN ROCK
Practice Address - State:NJ
Practice Address - Zip Code:07452-1402
Practice Address - Country:US
Practice Address - Phone:201-652-6067
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-03
Last Update Date:2020-07-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJSIO1674103TC0700X
NJ35SI00167400103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ6356605Medicaid
NJ6356605Medicaid