Provider Demographics
NPI:1679095178
Name:WALLACE, CATHERINE KELLY
Entity Type:Individual
Prefix:MISS
First Name:CATHERINE
Middle Name:KELLY
Last Name:WALLACE
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:625 DELAWARE AVE STE 204
Mailing Address - Street 2:
Mailing Address - City:BUFFALO
Mailing Address - State:NY
Mailing Address - Zip Code:14202-1007
Mailing Address - Country:US
Mailing Address - Phone:716-882-3151
Mailing Address - Fax:716-886-4022
Practice Address - Street 1:625 DELAWARE AVE STE 204
Practice Address - Street 2:
Practice Address - City:BUFFALO
Practice Address - State:NY
Practice Address - Zip Code:14202-1007
Practice Address - Country:US
Practice Address - Phone:716-882-3151
Practice Address - Fax:716-886-4022
Is Sole Proprietor?:No
Enumeration Date:2017-07-17
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor