Provider Demographics
NPI:1942368618
Name:WALLACE, ROBIN (MED)
Entity Type:Individual
Prefix:
First Name:ROBIN
Middle Name:
Last Name:WALLACE
Suffix:
Gender:F
Credentials:MED
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:91 CLAY POND RD
Mailing Address - Street 2:
Mailing Address - City:BOURNE
Mailing Address - State:MA
Mailing Address - Zip Code:02532-4239
Mailing Address - Country:US
Mailing Address - Phone:508-759-6101
Mailing Address - Fax:
Practice Address - Street 1:2 SCHOOL ST
Practice Address - Street 2:
Practice Address - City:PLYMOUTH
Practice Address - State:MA
Practice Address - Zip Code:02360-3964
Practice Address - Country:US
Practice Address - Phone:508-830-1234
Practice Address - Fax:508-830-1190
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-05
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)