Provider Demographics
NPI:1821605429
Name:WALLACK, CHRISTOPHER PETER I
Entity Type:Individual
Prefix:MR
First Name:CHRISTOPHER
Middle Name:PETER
Last Name:WALLACK
Suffix:I
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 1:85 AUSTIN ST
Mailing Address - Street 2:
Mailing Address - City:HYDE PARK
Mailing Address - State:MA
Mailing Address - Zip Code:02136-1532
Mailing Address - Country:US
Mailing Address - Phone:239-269-8276
Mailing Address - Fax:
Practice Address - Street 1:460 QUINCY AVE
Practice Address - Street 2:
Practice Address - City:QUINCY
Practice Address - State:MA
Practice Address - Zip Code:02169-8130
Practice Address - Country:US
Practice Address - Phone:239-269-8276
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-09-28
Last Update Date:2020-09-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health