Provider Demographics
NPI:1295907079
Name:WALLACE, REBECCA C (LIC AC)
Entity type:Individual
Prefix:
First Name:REBECCA
Middle Name:C
Last Name:WALLACE
Suffix:
Gender:F
Credentials:LIC AC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:THE WELL FOR INTEGRATIVE MEDICINE
Mailing Address - Street 2:114 MAIN STREET
Mailing Address - City:GLOUCESTER
Mailing Address - State:MA
Mailing Address - Zip Code:01930
Mailing Address - Country:US
Mailing Address - Phone:978-283-9600
Mailing Address - Fax:
Practice Address - Street 1:THE WELL FOR INTEGRATIVE MEDICINE
Practice Address - Street 2:114 MAIN STREET
Practice Address - City:GLOUCESTER
Practice Address - State:MA
Practice Address - Zip Code:01930
Practice Address - Country:US
Practice Address - Phone:978-283-9600
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-04-01
Last Update Date:2008-04-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA222854171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171100000XOther Service ProvidersAcupuncturist