Provider Demographics
NPI:1790839728
Name:WALLACE, JOSEPH PATRICK JR (PHD)
Entity Type:Individual
Prefix:
First Name:JOSEPH
Middle Name:PATRICK
Last Name:WALLACE
Suffix:JR
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:44 NORTH STREET
Mailing Address - Street 2:
Mailing Address - City:DANBURY
Mailing Address - State:CT
Mailing Address - Zip Code:06810
Mailing Address - Country:US
Mailing Address - Phone:203-743-4065
Mailing Address - Fax:914-248-1615
Practice Address - Street 1:44 NORTH STREET
Practice Address - Street 2:
Practice Address - City:DANBURY
Practice Address - State:CT
Practice Address - Zip Code:06810
Practice Address - Country:US
Practice Address - Phone:203-743-4065
Practice Address - Fax:914-248-1615
Is Sole Proprietor?:No
Enumeration Date:2007-01-23
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT000905103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical