Provider Demographics
NPI:1124662929
Name:WALLACE, LANEY ELIZABETH (MPS, LCAT, ATR-BC)
Entity type:Individual
Prefix:
First Name:LANEY
Middle Name:ELIZABETH
Last Name:WALLACE
Suffix:
Gender:F
Credentials:MPS, LCAT, ATR-BC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:300 COLES ST APT 506
Mailing Address - Street 2:
Mailing Address - City:JERSEY CITY
Mailing Address - State:NJ
Mailing Address - Zip Code:07310-1046
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:515 MADISON AVE FL 21
Practice Address - Street 2:
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10022-5433
Practice Address - Country:US
Practice Address - Phone:515-577-6281
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-11-05
Last Update Date:2019-11-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY002041221700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes221700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersArt Therapist