Individual
KEYONNA WALLACE
Active
Sole proprietor
Yes
Provider details
NPI number
Gender
F
Contact information
Practice address
8002 KEW GARDENS RD STE 704, KEW GARDENS, NY 11415-3607
(718) 520-1513
Mailing address
79 GLENRIDGE RD, GLENVILLE, NY 12302-4523
Taxonomy
Speciality
Code
Description
License number
State
101YA0400X
Addiction (Substance Use Disorder) Counselor
Primary
31387
NY
Other
Other identifiers
Code
Description
Identifier
Issuer
State
05
—
01420795
—
NY
Enumeration date
01/08/2020
Last updated
10/19/2020
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