Provider Demographics
NPI:1902588015
Name:WALLACE, TANYA B
Entity type:Individual
Prefix:
First Name:TANYA
Middle Name:B
Last Name:WALLACE
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:TANYA
Other - Middle Name:B
Other - Last Name:HARRIGAN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:1068 HASTINGS ST
Mailing Address - Street 2:
Mailing Address - City:BALDWIN
Mailing Address - State:NY
Mailing Address - Zip Code:11510-4741
Mailing Address - Country:US
Mailing Address - Phone:516-943-1622
Mailing Address - Fax:
Practice Address - Street 1:1068 HASTINGS ST
Practice Address - Street 2:
Practice Address - City:BALDWIN
Practice Address - State:NY
Practice Address - Zip Code:11510-4741
Practice Address - Country:US
Practice Address - Phone:516-943-1622
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-08-07
Last Update Date:2023-08-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselorGroup - Single Specialty