Provider Demographics
NPI:1750639928
Name:WALLACE, WINSTON
Entity Type:Individual
Prefix:MR
First Name:WINSTON
Middle Name:
Last Name:WALLACE
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11454 198TH ST
Mailing Address - Street 2:
Mailing Address - City:SAINT ALBANS
Mailing Address - State:NY
Mailing Address - Zip Code:11412-2821
Mailing Address - Country:US
Mailing Address - Phone:718-506-6968
Mailing Address - Fax:
Practice Address - Street 1:11454 198TH ST
Practice Address - Street 2:
Practice Address - City:SAINT ALBANS
Practice Address - State:NY
Practice Address - Zip Code:11412-2821
Practice Address - Country:US
Practice Address - Phone:718-506-6968
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-08-20
Last Update Date:2012-08-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health