Provider Demographics
NPI:1366004780
Name:WALLACE, CATHERINE L (CCC/SLP)
Entity Type:Individual
Prefix:MS
First Name:CATHERINE
Middle Name:L
Last Name:WALLACE
Suffix:
Gender:F
Credentials:CCC/SLP
Other - Prefix:MS
Other - First Name:CAYTE
Other - Middle Name:
Other - Last Name:WILLIAMS
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:170 17TH ST STE B
Mailing Address - Street 2:
Mailing Address - City:PACIFIC GROVE
Mailing Address - State:CA
Mailing Address - Zip Code:93950-7201
Mailing Address - Country:US
Mailing Address - Phone:831-318-0558
Mailing Address - Fax:
Practice Address - Street 1:170 17TH ST STE B
Practice Address - Street 2:
Practice Address - City:PACIFIC GROVE
Practice Address - State:CA
Practice Address - Zip Code:93950-7201
Practice Address - Country:US
Practice Address - Phone:831-318-0558
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-07-05
Last Update Date:2022-06-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAD7898365235Z00000X
CA27865235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist