Individual
CHARLES JEROME WALLACE
Active
Sole proprietor
Yes
Provider details
NPI number
Gender
Man
Credential
CASAC-T
Contact information
Practice address
55 W 125TH ST FL 11, NEW YORK, NY 10027-4516
(212) 864-4128
(212) 662-9193
Mailing address
55 W 125TH ST FL 11, NEW YORK, NY 10027-4516
(212) 864-4128
(212) 662-9193
Taxonomy
Speciality
Code
Description
License number
State
101YA0400X
Addiction (Substance Use Disorder) Counselor
Primary
—
NY
Other
Enumeration date
03/16/2017
Last updated
03/16/2017
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