Provider Demographics
NPI:1184644395
Name:CONNIE WALLAE
Entity Type:Organization
Organization Name:CONNIE WALLAE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MFT
Authorized Official - Prefix:MRS
Authorized Official - First Name:CONNIE
Authorized Official - Middle Name:
Authorized Official - Last Name:WALLACE
Authorized Official - Suffix:
Authorized Official - Credentials:MFT
Authorized Official - Phone:661-205-1522
Mailing Address - Street 1:1706 CHESTER AVE
Mailing Address - Street 2:SUITE 340
Mailing Address - City:BAKERSFIELD
Mailing Address - State:CA
Mailing Address - Zip Code:93301-5242
Mailing Address - Country:US
Mailing Address - Phone:661-205-1522
Mailing Address - Fax:661-873-0515
Practice Address - Street 1:1706 CHESTER AVE
Practice Address - Street 2:SUITE 340
Practice Address - City:BAKERSFIELD
Practice Address - State:CA
Practice Address - Zip Code:93301-5242
Practice Address - Country:US
Practice Address - Phone:661-205-1522
Practice Address - Fax:661-873-0515
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-20
Last Update Date:2008-08-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAMFC 40616106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family TherapistGroup - Single Specialty