Provider Demographics
NPI:1891099115
Name:WALLACE, ARLENE DENISE (EDD)
Entity Type:Individual
Prefix:
First Name:ARLENE
Middle Name:DENISE
Last Name:WALLACE
Suffix:
Gender:F
Credentials:EDD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8144 FORREST AVE
Mailing Address - Street 2:
Mailing Address - City:PHILADELPHIA
Mailing Address - State:PA
Mailing Address - Zip Code:19150-2402
Mailing Address - Country:US
Mailing Address - Phone:215-407-3442
Mailing Address - Fax:
Practice Address - Street 1:8144 FORREST AVE
Practice Address - Street 2:
Practice Address - City:PHILADELPHIA
Practice Address - State:PA
Practice Address - Zip Code:19150-2402
Practice Address - Country:US
Practice Address - Phone:215-407-3442
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-12-29
Last Update Date:2010-12-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst