Individual
JUSTINE WALLACE
Active
Sole proprietor
No
Provider details
NPI number
Gender
F
Contact information
Practice address
419 CEDAR ST, NEWINGTON, CT 06111-1812
(561) 271-5185
Mailing address
419 CEDAR ST, NEWINGTON, CT 06111-1812
Taxonomy
Speciality
Code
Description
License number
State
101YP2500X
Professional Counselor
Primary
001902
CT
Other
Enumeration date
08/25/2010
Last updated
08/25/2010
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