Provider Demographics
NPI:1790095859
Name:WALLES, SARA (LCSW)
Entity Type:Individual
Prefix:MRS
First Name:SARA
Middle Name:
Last Name:WALLES
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12 LORRAINE DR.
Mailing Address - Street 2:
Mailing Address - City:CLIFTON
Mailing Address - State:NJ
Mailing Address - Zip Code:07012
Mailing Address - Country:US
Mailing Address - Phone:720-295-8285
Mailing Address - Fax:
Practice Address - Street 1:729 VAN HOUTEN AVE.
Practice Address - Street 2:SUITE #2
Practice Address - City:CLIFTON
Practice Address - State:NJ
Practice Address - Zip Code:07013
Practice Address - Country:US
Practice Address - Phone:720-295-8285
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-10-07
Last Update Date:2016-12-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
104100000X
NJ44SC05662001041C0700X
NY0821921041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No104100000XBehavioral Health & Social Service ProvidersSocial Worker