Provider Demographics
NPI:1851543979
Name:WALLACE, WARREN S (EDD, LPC)
Entity Type:Individual
Prefix:DR
First Name:WARREN
Middle Name:S
Last Name:WALLACE
Suffix:
Gender:M
Credentials:EDD, LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:33 BERKSHIRE DR
Mailing Address - Street 2:
Mailing Address - City:SEWELL
Mailing Address - State:NJ
Mailing Address - Zip Code:08080-3104
Mailing Address - Country:US
Mailing Address - Phone:856-302-5371
Mailing Address - Fax:856-228-0999
Practice Address - Street 1:33 BERKSHIRE DR
Practice Address - Street 2:
Practice Address - City:SEWELL
Practice Address - State:NJ
Practice Address - Zip Code:08080-3104
Practice Address - Country:US
Practice Address - Phone:856-302-5371
Practice Address - Fax:856-228-0999
Is Sole Proprietor?:Yes
Enumeration Date:2008-10-21
Last Update Date:2008-10-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ37PC00165300101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional