| Jill N Wallace Lcsw Pllc | |
|
15 Heath Ln East Northport NY 11731-1912 | |
| (516) 459-0312 | |
| Not Available |
| Full Name | Jill N Wallace Lcsw Pllc |
|---|---|
| Speciality | Social Worker |
| Location | 15 Heath Ln, East Northport, New York |
| Authorized Official Name and Position | Jill N Wallace (OWNER) |
| Authorized Official Contact | 5164590312 |
| Accepts Medicare Insurance | Yes. This clinic participates in medicare program and accept medicare insurance. |
| Mailing Address | Practice Location Address |
|---|---|
| Jill N Wallace Lcsw Pllc 15 Heath Ln East Northport NY 11731-1912 Ph: (516) 459-0312 | Jill N Wallace Lcsw Pllc 15 Heath Ln East Northport NY 11731-1912 Ph: (516) 459-0312 |
| NPI Number | 1356760037 |
|---|---|
| Provider Enumeration Date | 04/10/2014 |
| Last Update Date | 07/19/2024 |
| Certification Date | 07/19/2024 |
| Medicare PECOS PAC ID | 4981824760 |
|---|---|
| Medicare Enrollment ID | O20140929001859 |
| Identifier | Type | State | Issuer |
|---|---|---|---|
| 1356760037 | NPI | - | NPPES |
| Taxonomy | Type | License (State) | Status |
|---|---|---|---|
| 104100000X | Social Worker | R045832 (New York) | Primary |
| Provider Name | Jill Wallace |
|---|---|
| Provider Type | Practitioner - Clinical Social Worker |
| Provider Identifiers | NPI Number: 1902985724 PECOS PAC ID: 4688707680 Enrollment ID: I20141231000038 |
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