1659706240 NPI number — EMILY MARIE WALLACE LMHC

Table of content: EMILY MARIE WALLACE LMHC (NPI 1659706240)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1659706240 NPI number — EMILY MARIE WALLACE LMHC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
WALLACE
Provider First Name:
EMILY
Provider Middle Name:
MARIE
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
LMHC
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
ABRUZZESE
Provider Other First Name:
EMILY
Provider Other Middle Name:
MARIE
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1659706240
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
03/16/2016
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
119 RUSSELL STREET
Provider Second Line Business Mailing Address:
NEW ENGLAND CENTER FOR MENTAL HEALTH
Provider Business Mailing Address City Name:
LITTLETON
Provider Business Mailing Address State Name:
MA
Provider Business Mailing Address Postal Code:
01460
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
978-856-4938
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
119 RUSSELL STREET
Provider Second Line Business Practice Location Address:
NEW ENGLAND CENTER FOR MENTAL HEALTH
Provider Business Practice Location Address City Name:
LITTLETON
Provider Business Practice Location Address State Name:
MA
Provider Business Practice Location Address Postal Code:
01460-3076
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
978-679-1200
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
09/13/2013

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 101YM0800X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)