Provider Demographics
NPI:1710780507
Name:WALLACE, JOSHUA (BS, MA)
Entity type:Individual
Prefix:
First Name:JOSHUA
Middle Name:
Last Name:WALLACE
Suffix:
Gender:M
Credentials:BS, MA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9007 WASHINGTON ST NE
Mailing Address - Street 2:
Mailing Address - City:ALBUQUERQUE
Mailing Address - State:NM
Mailing Address - Zip Code:87113-2722
Mailing Address - Country:US
Mailing Address - Phone:505-699-8531
Mailing Address - Fax:
Practice Address - Street 1:9007 WASHINGTON ST NE
Practice Address - Street 2:
Practice Address - City:ALBUQUERQUE
Practice Address - State:NM
Practice Address - Zip Code:87113-2722
Practice Address - Country:US
Practice Address - Phone:505-699-8531
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2025-03-28
Last Update Date:2025-03-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health