Provider Demographics
NPI:1003238205
Name:WALLACH, EDWARD S (LCSW, PHD)
Entity type:Individual
Prefix:MR
First Name:EDWARD
Middle Name:S
Last Name:WALLACH
Suffix:
Gender:M
Credentials:LCSW, PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:673 STEWART AVENUE
Mailing Address - Street 2:
Mailing Address - City:STATEN ISLAND
Mailing Address - State:NY
Mailing Address - Zip Code:10314
Mailing Address - Country:US
Mailing Address - Phone:718-698-1795
Mailing Address - Fax:718-698-9357
Practice Address - Street 1:673 STEWART AVENUE
Practice Address - Street 2:
Practice Address - City:STATEN ISLAND
Practice Address - State:NY
Practice Address - Zip Code:10314
Practice Address - Country:US
Practice Address - Phone:718-698-1795
Practice Address - Fax:718-698-9357
Is Sole Proprietor?:Yes
Enumeration Date:2014-01-08
Last Update Date:2014-01-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYR0272931041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical