Provider Demographics
NPI:1639821762
Name:WALLACE, BARBARA CORNELIA
Entity Type:Individual
Prefix:
First Name:BARBARA
Middle Name:CORNELIA
Last Name:WALLACE
Suffix:
Gender:F
Credentials:
Other - Prefix:DR
Other - First Name:BARBARA
Other - Middle Name:C
Other - Last Name:WALLACE
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:PHD
Mailing Address - Street 1:1730 N 27TH ST
Mailing Address - Street 2:
Mailing Address - City:PHILADELPHIA
Mailing Address - State:PA
Mailing Address - Zip Code:19121-2851
Mailing Address - Country:US
Mailing Address - Phone:267-269-7411
Mailing Address - Fax:
Practice Address - Street 1:525 W 120TH ST STE 530H
Practice Address - Street 2:
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10027-6605
Practice Address - Country:US
Practice Address - Phone:267-269-7411
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-01-20
Last Update Date:2022-01-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY09450-1103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist