Provider Demographics
NPI:1053473884
Name:WALLACE, MALCOLM LOUIS
Entity Type:Individual
Prefix:
First Name:MALCOLM
Middle Name:LOUIS
Last Name:WALLACE
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1517 MACARTHUR BLVD
Mailing Address - Street 2:7
Mailing Address - City:OAKLAND
Mailing Address - State:CA
Mailing Address - Zip Code:94602-1264
Mailing Address - Country:US
Mailing Address - Phone:408-910-8252
Mailing Address - Fax:
Practice Address - Street 1:982 MISSION ST
Practice Address - Street 2:
Practice Address - City:SAN FRANCISCO
Practice Address - State:CA
Practice Address - Zip Code:94103-2911
Practice Address - Country:US
Practice Address - Phone:415-597-8000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-12-15
Last Update Date:2016-02-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA41906OtherUNICARE