Provider Demographics
NPI:1588049506
Name:WALLACE, ALYSSA (MS SLP)
Entity type:Individual
Prefix:
First Name:ALYSSA
Middle Name:
Last Name:WALLACE
Suffix:
Gender:F
Credentials:MS SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8864 WARNER RD
Mailing Address - Street 2:
Mailing Address - City:WAYLAND
Mailing Address - State:NY
Mailing Address - Zip Code:14572-9387
Mailing Address - Country:US
Mailing Address - Phone:607-765-1700
Mailing Address - Fax:
Practice Address - Street 1:2350 ROUTE 63
Practice Address - Street 2:
Practice Address - City:WAYLAND
Practice Address - State:NY
Practice Address - Zip Code:14572-9509
Practice Address - Country:US
Practice Address - Phone:607-765-1700
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-07-21
Last Update Date:2020-04-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY024855235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist