Provider Demographics
NPI:1215051917
Name:WALLACE, JAMES IRWIN (PHD)
Entity type:Individual
Prefix:DR
First Name:JAMES
Middle Name:IRWIN
Last Name:WALLACE
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7295 BUTTERNUT LN
Mailing Address - Street 2:
Mailing Address - City:HAMILTON
Mailing Address - State:NY
Mailing Address - Zip Code:13346-2124
Mailing Address - Country:US
Mailing Address - Phone:315-824-5809
Mailing Address - Fax:
Practice Address - Street 1:40 MILFORD ST
Practice Address - Street 2:
Practice Address - City:HAMILTON
Practice Address - State:NY
Practice Address - Zip Code:13346-1009
Practice Address - Country:US
Practice Address - Phone:315-750-6497
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-19
Last Update Date:2011-12-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY009265103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical