Doctor Name: | DENISE WALLACK |
NPI Number: | 1326401969 |
Entity Type Code: | Individual (1) |
Gender: | F |
Credentials: | PSY.D. |
License Number: | 35SI00558100 |
Business Practice Address: | 470 Forest St Unit 2 Kearny, NJ - 070323582 |
Business Phone Number: | 9737157593 |
Business Fax Number: | |
Mailing Address: | 470 Forest St, Unit 2 KEARNY |
State: | NJ |
Postal Code: | 070323582 |
Phone Number: | 9737157593 |
Fax Number: | |
NPI Enumeration Date: | 03/31/2016 |
NPI Last Update Date: | 03/31/2016 |
Replacement NPI: | 0 |
NPI Deactivation Date: | |
NPI Reactivation Date: |
Taxonomy Information: | |
Healthcare Provider Taxonomy: | 103TB0200X |
License Number: | 35SI00558100 |
Healthcare Provider Taxonomy: (Secondary) | Y |
State: | NJ |
Taxonomy Type: | Behavioral Health & Social Service Providers |
Taxonomy Classification: | Psychologist |
Taxonomy Specialization: | Cognitive & Behavioral |
Taxonomy Definition: |