Provider Demographics
NPI:1457752289
Name:WALLACE, CAROLINE (BA)
Entity Type:Individual
Prefix:MISS
First Name:CAROLINE
Middle Name:
Last Name:WALLACE
Suffix:
Gender:F
Credentials:BA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:275 PROSPECT ST
Mailing Address - Street 2:
Mailing Address - City:NORWOOD
Mailing Address - State:MA
Mailing Address - Zip Code:02062-1467
Mailing Address - Country:US
Mailing Address - Phone:781-255-1817
Mailing Address - Fax:781-762-8542
Practice Address - Street 1:275 PROSPECT ST
Practice Address - Street 2:
Practice Address - City:NORWOOD
Practice Address - State:MA
Practice Address - Zip Code:02062-1467
Practice Address - Country:US
Practice Address - Phone:781-255-1817
Practice Address - Fax:781-762-8542
Is Sole Proprietor?:Yes
Enumeration Date:2014-09-11
Last Update Date:2014-09-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist