Provider Demographics
NPI:1982894564
Name:WALLACE, SETH WILLARD (PHD, MS, LPC)
Entity Type:Individual
Prefix:DR
First Name:SETH
Middle Name:WILLARD
Last Name:WALLACE
Suffix:
Gender:M
Credentials:PHD, MS, LPC
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 303
Mailing Address - Street 2:
Mailing Address - City:KENSINGTON
Mailing Address - State:CT
Mailing Address - Zip Code:06037-0303
Mailing Address - Country:US
Mailing Address - Phone:860-817-1331
Mailing Address - Fax:
Practice Address - Street 1:1224 FARMINGTON AVE
Practice Address - Street 2:UNIT D
Practice Address - City:KENSINGTON
Practice Address - State:CT
Practice Address - Zip Code:06037-2360
Practice Address - Country:US
Practice Address - Phone:860-817-1331
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-07-30
Last Update Date:2012-04-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT001604101YP2500X
CT070 CERTIFICATION103TS0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
No103TS0200XBehavioral Health & Social Service ProvidersPsychologistSchool
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT001604OtherLICENSE NUMBER AS PROFESS