Individual
DR. RANDALL KENT WALLACE
Active
Sole proprietor
Yes
Provider details
NPI number
Gender
Man
Credential
PSY.D.
Contact information
Practice address
36 RUSS ST, HARTFORD, CT 06106-1520
(860) 466-9411
Mailing address
36 RUSS ST, HARTFORD, CT 06106-1520
(860) 466-9411
Taxonomy
Speciality
Code
Description
License number
State
103TC0700X
Clinical Psychologist
Primary
2544
CT
Other
Enumeration date
11/09/2012
Last updated
11/09/2016
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