Provider Demographics
NPI:1821609926
Name:WALLACH, TRACY (MSW, PHD)
Entity Type:Individual
Prefix:DR
First Name:TRACY
Middle Name:
Last Name:WALLACH
Suffix:
Gender:F
Credentials:MSW, PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:96 BROWNE ST APT 1
Mailing Address - Street 2:
Mailing Address - City:BROOKLINE
Mailing Address - State:MA
Mailing Address - Zip Code:02446-7257
Mailing Address - Country:US
Mailing Address - Phone:617-566-0070
Mailing Address - Fax:
Practice Address - Street 1:96 BROWNE ST APT 1
Practice Address - Street 2:
Practice Address - City:BROOKLINE
Practice Address - State:MA
Practice Address - Zip Code:02446-7257
Practice Address - Country:US
Practice Address - Phone:617-566-0070
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-08-12
Last Update Date:2020-08-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA1064451041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical