Individual
ROBERT LEE WALLACE SR.
Active
Sole proprietor
No
Provider details
NPI number
Gender
Man
Contact information
Practice address
100 WILLOW ST, LYNN, MA 01901-1139
(781) 691-7060
(781) 691-7064
Mailing address
100 WILLOW ST, LYNN, MA 01901-1139
(781) 691-7060
(781) 691-7064
Taxonomy
Speciality
Code
Description
License number
State
171M00000X
Case Manager/Care Coordinator
Primary
—
MA
Other
Other identifiers
Code
Description
Identifier
Issuer
State
05
—
171M00000X
—
MA
Enumeration date
12/04/2019
Last updated
12/04/2019
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