Provider Demographics
NPI:1174372767
Name:WALLACE, BRADLEY (MA)
Entity type:Individual
Prefix:MR
First Name:BRADLEY
Middle Name:
Last Name:WALLACE
Suffix:
Gender:M
Credentials:MA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:175 FEDERAL ST
Mailing Address - Street 2:ST 1400
Mailing Address - City:BOSTON
Mailing Address - State:MA
Mailing Address - Zip Code:02110-2237
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:175 FEDERAL ST STE 1400
Practice Address - Street 2:
Practice Address - City:BOSTON
Practice Address - State:MA
Practice Address - Zip Code:02110-2237
Practice Address - Country:US
Practice Address - Phone:617-336-3246
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-05-15
Last Update Date:2024-05-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health