Provider Demographics
NPI:1225315476
Name:WALLACE, LINDSAY MICHELLE (RAS)
Entity Type:Individual
Prefix:MISS
First Name:LINDSAY
Middle Name:MICHELLE
Last Name:WALLACE
Suffix:
Gender:F
Credentials:RAS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:17279 MCFADDEN AVE
Mailing Address - Street 2:APT A
Mailing Address - City:TUSTIN
Mailing Address - State:CA
Mailing Address - Zip Code:92780-5577
Mailing Address - Country:US
Mailing Address - Phone:562-243-5164
Mailing Address - Fax:
Practice Address - Street 1:321 N STATE COLLEGE BLVD
Practice Address - Street 2:
Practice Address - City:ANAHEIM
Practice Address - State:CA
Practice Address - Zip Code:92806-2915
Practice Address - Country:US
Practice Address - Phone:714-687-0077
Practice Address - Fax:714-687-0691
Is Sole Proprietor?:Yes
Enumeration Date:2011-11-15
Last Update Date:2011-11-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)