Provider Demographics
NPI:1093487357
Name:WALLACE, DARIUS ISIAHY
Entity Type:Individual
Prefix:
First Name:DARIUS
Middle Name:ISIAHY
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 1:427 PAJARO ST STE 4
Mailing Address - Street 2:
Mailing Address - City:SALINAS
Mailing Address - State:CA
Mailing Address - Zip Code:93901-3459
Mailing Address - Country:US
Mailing Address - Phone:831-424-6655
Mailing Address - Fax:831-424-9717
Practice Address - Street 1:427 PAJARO ST STE 4
Practice Address - Street 2:
Practice Address - City:SALINAS
Practice Address - State:CA
Practice Address - Zip Code:93901-3459
Practice Address - Country:US
Practice Address - Phone:831-424-6655
Practice Address - Fax:831-424-9717
Is Sole Proprietor?:No
Enumeration Date:2021-10-04
Last Update Date:2021-10-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAR1408181020101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)