Provider Demographics
NPI:1275359135
Name:LUDEL, WALLACE
Entity type:Individual
Prefix:
First Name:WALLACE
Middle Name:
Last Name:LUDEL
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:580 FLATBUSH AVE APT 5D
Mailing Address - Street 2:
Mailing Address - City:BROOKLYN
Mailing Address - State:NY
Mailing Address - Zip Code:11225-4921
Mailing Address - Country:US
Mailing Address - Phone:310-365-5704
Mailing Address - Fax:
Practice Address - Street 1:285 LEXINGTON AVE STE 2A
Practice Address - Street 2:
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10016-3570
Practice Address - Country:US
Practice Address - Phone:310-365-5704
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-11-25
Last Update Date:2024-11-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY1209321041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical