Provider Demographics
NPI:1568811537
Name:WALLACH, JONATHAN (LMHC)
Entity Type:Individual
Prefix:
First Name:JONATHAN
Middle Name:
Last Name:WALLACH
Suffix:
Gender:M
Credentials:LMHC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2019 GALISTEO ST
Mailing Address - Street 2:SUITE E2
Mailing Address - City:SANTA FE
Mailing Address - State:NM
Mailing Address - Zip Code:87505-2143
Mailing Address - Country:US
Mailing Address - Phone:505-983-8225
Mailing Address - Fax:
Practice Address - Street 1:2019 GALISTEO ST
Practice Address - Street 2:SUITE E2
Practice Address - City:SANTA FE
Practice Address - State:NM
Practice Address - Zip Code:87505-2143
Practice Address - Country:US
Practice Address - Phone:505-983-8225
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-06-09
Last Update Date:2016-06-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NM0181511101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health