Provider Demographics
NPI:1235014044
Name:JONATHAN WALLACH LPCC LLC
Entity type:Organization
Organization Name:JONATHAN WALLACH LPCC LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:BILLING SUPERVISOR
Authorized Official - Prefix:
Authorized Official - First Name:MONA
Authorized Official - Middle Name:
Authorized Official - Last Name:HOOVER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:217-621-6595
Mailing Address - Street 1:13 LOMA SERENA
Mailing Address - Street 2:
Mailing Address - City:SANTA FE
Mailing Address - State:NM
Mailing Address - Zip Code:87506-7531
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1010 MARQUEZ PL STE C
Practice Address - Street 2:
Practice Address - City:SANTA FE
Practice Address - State:NM
Practice Address - Zip Code:87505-1694
Practice Address - Country:US
Practice Address - Phone:780-822-6795
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2025-08-11
Last Update Date:2025-08-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental HealthGroup - Single Specialty