Provider Demographics
NPI:1205053741
Name:WALLENSTEIN, LAWRENCE (LCSW)
Entity type:Individual
Prefix:MR
First Name:LAWRENCE
Middle Name:
Last Name:WALLENSTEIN
Suffix:
Gender:M
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 451
Mailing Address - Street 2:
Mailing Address - City:BINGHAMTON
Mailing Address - State:NY
Mailing Address - Zip Code:13903-0451
Mailing Address - Country:US
Mailing Address - Phone:607-761-7896
Mailing Address - Fax:
Practice Address - Street 1:52 WOODLAND AVE
Practice Address - Street 2:
Practice Address - City:BINGHAMTON
Practice Address - State:NY
Practice Address - Zip Code:13903-3336
Practice Address - Country:US
Practice Address - Phone:607-761-7896
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-04-19
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY070921-1261QR0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QR0400XAmbulatory Health Care FacilitiesClinic/CenterRehabilitation
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY02751866Medicaid