Basic Information
| Provider Information | |||||||||
| NPI: | 1003916313 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | VARONKO | ||||||||
| FirstName: | WALLACE | ||||||||
| MiddleName: | WILLIAM | ||||||||
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| Credential: | PHD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 78 BOLAS ROAD | ||||||||
| Address2: | |||||||||
| City: | DUXBURY | ||||||||
| State: | MA | ||||||||
| PostalCode: | 02332 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7815823838 | ||||||||
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| Practice Location | |||||||||
| Address1: | 30 TAUNTON GREENE SUITE 5 | ||||||||
| Address2: | |||||||||
| City: | TAUNTON | ||||||||
| State: | MA | ||||||||
| PostalCode: | 02780 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5088806666 | ||||||||
| FaxNumber: | 5088806655 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/25/2006 | ||||||||
| LastUpdateDate: | 07/09/2007 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 103TC1900X | 4573 | MA | Y | Behavioral Health & Social Service Providers | Psychologist | Counseling |
ID Information
| ID | Type | State | Issuer | Description | 1311778 | 05 | MA | MEDICAID |