Provider Demographics
NPI:1720600158
Name:BZDELL, WALLACE BRENT (EDD)
Entity Type:Individual
Prefix:DR
First Name:WALLACE
Middle Name:BRENT
Last Name:BZDELL
Suffix:
Gender:M
Credentials:EDD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7 SOMERSET LN
Mailing Address - Street 2:
Mailing Address - City:SCOTIA
Mailing Address - State:NY
Mailing Address - Zip Code:12302-2718
Mailing Address - Country:US
Mailing Address - Phone:518-330-4753
Mailing Address - Fax:
Practice Address - Street 1:7 SOMERSET LN
Practice Address - Street 2:
Practice Address - City:SCOTIA
Practice Address - State:NY
Practice Address - Zip Code:12302-2718
Practice Address - Country:US
Practice Address - Phone:518-330-4753
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-05-07
Last Update Date:2020-05-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY015981-1103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist