Provider Demographics
NPI:1164676029
Name:WALLMAN, MARK ALLEN SR (LPC, LCADC)
Entity type:Individual
Prefix:MR
First Name:MARK
Middle Name:ALLEN
Last Name:WALLMAN
Suffix:SR
Gender:M
Credentials:LPC, LCADC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:314 KELLY LN
Mailing Address - Street 2:
Mailing Address - City:BOONTON
Mailing Address - State:NJ
Mailing Address - Zip Code:07005-2110
Mailing Address - Country:US
Mailing Address - Phone:973-334-6006
Mailing Address - Fax:
Practice Address - Street 1:314 KELLY LN
Practice Address - Street 2:
Practice Address - City:BOONTON
Practice Address - State:NJ
Practice Address - Zip Code:07005-2110
Practice Address - Country:US
Practice Address - Phone:973-334-6006
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-11-05
Last Update Date:2009-05-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ37PC00384900101YP2500X
NJ37LC00156700101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)