Provider Demographics
NPI:1184694473
Name:WALLACE, LINDA M (CCC-A)
Entity type:Individual
Prefix:
First Name:LINDA
Middle Name:M
Last Name:WALLACE
Suffix:
Gender:F
Credentials:CCC-A
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:133 BROOKLINE AVE
Mailing Address - Street 2:
Mailing Address - City:BOSTON
Mailing Address - State:MA
Mailing Address - Zip Code:02215-3904
Mailing Address - Country:US
Mailing Address - Phone:617-421-5984
Mailing Address - Fax:
Practice Address - Street 1:1611 CAMBRIDGE ST
Practice Address - Street 2:
Practice Address - City:CAMBRIDGE
Practice Address - State:MA
Practice Address - Zip Code:02138-4302
Practice Address - Country:US
Practice Address - Phone:617-661-5525
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-01-26
Last Update Date:2009-10-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA388231H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes231H00000XSpeech, Language and Hearing Service ProvidersAudiologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MAB501027OtherCIGNA
MAPJ183OtherHARVARD PILGRIM
MA0014863OtherNEIGHBORHOOD HEALTH PLAN
MA5103053Medicaid
MAAD0161OtherBLUE CROSS
MAAD0161OtherBLUE CROSS