Provider Demographics
NPI:1114472735
Name:WALLACE, REBECCA M (PSYD)
Entity Type:Individual
Prefix:DR
First Name:REBECCA
Middle Name:M
Last Name:WALLACE
Suffix:
Gender:F
Credentials:PSYD
Other - Prefix:DR
Other - First Name:BECCA
Other - Middle Name:M
Other - Last Name:WALLACE
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:PSYD
Mailing Address - Street 1:1200 CHILDRENS AVE
Mailing Address - Street 2:STE 12400
Mailing Address - City:OKLAHOMA CITY
Mailing Address - State:OK
Mailing Address - Zip Code:73104-4637
Mailing Address - Country:US
Mailing Address - Phone:405-271-4407
Mailing Address - Fax:
Practice Address - Street 1:1200 CHILDRENS AVE
Practice Address - Street 2:STE 12400
Practice Address - City:OKLAHOMA CITY
Practice Address - State:OK
Practice Address - Zip Code:73104-4637
Practice Address - Country:US
Practice Address - Phone:405-271-4407
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-08-24
Last Update Date:2017-04-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AR1508APPL103TC0700X
OK1272103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical