Individual
DR. TIMOTHY R WALLACE
Active
Sole proprietor
Provider details
NPI number
Gender
Man
Credential
PHD
Contact information
Practice address
125 NASHUA STREET, SPAULDING REHAB HOSPITAL, BOSTON, MA 02114-1198
(617) 573-2694
(217) 573-2229
Mailing address
PO BOX 9142, MASS GENERAL PHYSICIAN ORGANIZATION, CHARLESTOWN, MA 02129-9142
(617) 724-0287
(617) 726-2894
Taxonomy
Speciality
Code
Description
License number
State
103T00000X
Psychologist
Primary
4282
MA
Other
Other identifiers
Code
Description
Identifier
Issuer
State
05
—
0395471
—
MA
01
—
456014
TUFTS
MA
01
—
W50958
BCBS MA
MA
Enumeration date
10/27/2005
Last updated
07/08/2007
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