Provider Demographics
NPI:1992311047
Name:WALLACE, ALYSSA MARIE (LMHC)
Entity type:Individual
Prefix:
First Name:ALYSSA
Middle Name:MARIE
Last Name:WALLACE
Suffix:
Gender:F
Credentials:LMHC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1045 JAMES ST STE 100
Mailing Address - Street 2:
Mailing Address - City:SYRACUSE
Mailing Address - State:NY
Mailing Address - Zip Code:13203-2758
Mailing Address - Country:US
Mailing Address - Phone:315-425-1004
Mailing Address - Fax:315-479-7884
Practice Address - Street 1:1045 JAMES ST STE 100
Practice Address - Street 2:
Practice Address - City:SYRACUSE
Practice Address - State:NY
Practice Address - Zip Code:13203-2758
Practice Address - Country:US
Practice Address - Phone:315-425-1004
Practice Address - Fax:315-479-7884
Is Sole Proprietor?:No
Enumeration Date:2020-09-23
Last Update Date:2023-05-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY01699101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health