Individual
DR. MAXWELL WALLACE
Active
Sole proprietor
Yes
Provider details
NPI number
Gender
Man
Credential
PSYD
Contact information
Practice address
600 PARK AVENUE, CARRIAGE HOUSE, ROCHESTER, NY 14607
(585) 449-0125
Mailing address
600 PARK AVENUE, CARRIAGE HOUSE, ROCHESTER, NY 14607
(585) 449-0125
Taxonomy
Speciality
Code
Description
License number
State
103TC0700X
Clinical Psychologist
Primary
022525
NY
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
6147215
AETNA
NY
Enumeration date
04/10/2018
Last updated
07/19/2018
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