Provider Demographics
NPI:1639676299
Name:WALLACE, MAXWELL (PSYD)
Entity Type:Individual
Prefix:DR
First Name:MAXWELL
Middle Name:
Last Name:WALLACE
Suffix:
Gender:M
Credentials:PSYD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:600 PARK AVENUE
Mailing Address - Street 2:CARRIAGE HOUSE
Mailing Address - City:ROCHESTER
Mailing Address - State:NY
Mailing Address - Zip Code:14607
Mailing Address - Country:US
Mailing Address - Phone:585-449-0125
Mailing Address - Fax:
Practice Address - Street 1:600 PARK AVENUE
Practice Address - Street 2:CARRIAGE HOUSE
Practice Address - City:ROCHESTER
Practice Address - State:NY
Practice Address - Zip Code:14607
Practice Address - Country:US
Practice Address - Phone:585-449-0125
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-04-10
Last Update Date:2018-07-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY022525103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY6147215OtherAETNA