| Doctor Name: | MR. EDWARD S WALLACH |
| NPI Number: | 1003238205 |
| Entity Type Code: | Individual (1) |
| Gender: | M |
| Credentials: | LCSW, PH.D. |
| License Number: | R027293 |
| Business Practice Address: | 673 Stewart Avenue Staten Island, NY - 10314 |
| Business Phone Number: | 7186981795 |
| Business Fax Number: | 7186989357 |
| Mailing Address: | 673 Stewart Avenue, STATEN ISLAND |
| State: | NY |
| Postal Code: | 10314 |
| Phone Number: | 7186981795 |
| Fax Number: | 7186989357 |
| NPI Enumeration Date: | 01/08/2014 |
| NPI Last Update Date: | 01/08/2014 |
| Replacement NPI: | 0 |
| NPI Deactivation Date: | |
| NPI Reactivation Date: |
Taxonomy Information: | |
| Healthcare Provider Taxonomy: | 1041C0700X |
| License Number: | R027293 |
| Healthcare Provider Taxonomy: (Secondary) | Y |
| State: | NY |
| Taxonomy Type: | Behavioral Health & Social Service Providers |
| Taxonomy Classification: | Social Worker |
| Taxonomy Specialization: | Clinical |
| Taxonomy Definition: | A social worker who holds a master |