Provider Demographics
NPI:1336415611
Name:DR JOSEPH WALLACH PHD LLC
Entity Type:Organization
Organization Name:DR JOSEPH WALLACH PHD LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:LICENSED CLINICAL PSYCHOLOGIST
Authorized Official - Prefix:DR
Authorized Official - First Name:JOSEPH
Authorized Official - Middle Name:
Authorized Official - Last Name:WALLACH
Authorized Official - Suffix:
Authorized Official - Credentials:PHD
Authorized Official - Phone:773-852-2400
Mailing Address - Street 1:2741 W GREENLEAF AVE
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60645-3013
Mailing Address - Country:US
Mailing Address - Phone:773-852-2400
Mailing Address - Fax:847-869-8116
Practice Address - Street 1:2530 CRAWFORD AVE
Practice Address - Street 2:SUITE 304
Practice Address - City:EVANSTON
Practice Address - State:IL
Practice Address - Zip Code:60201-4970
Practice Address - Country:US
Practice Address - Phone:773-852-2400
Practice Address - Fax:847-869-8116
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-03-30
Last Update Date:2012-03-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL071007942103TB0200X, 103TC0700X, 103TH0004X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinicalGroup - Single Specialty
No103TB0200XBehavioral Health & Social Service ProvidersPsychologistCognitive & BehavioralGroup - Single Specialty
No103TH0004XBehavioral Health & Social Service ProvidersPsychologistHealthGroup - Single Specialty