Provider Demographics
NPI:1427199157
Name:WALLACE-BURKE, PATRICIA FAYE (PHD)
Entity Type:Individual
Prefix:DR
First Name:PATRICIA
Middle Name:FAYE
Last Name:WALLACE-BURKE
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:DR
Other - First Name:PATRICIA
Other - Middle Name:FAYE
Other - Last Name:WALLACE
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:PHD
Mailing Address - Street 1:2008 N GAREY AVE
Mailing Address - Street 2:
Mailing Address - City:POMONA
Mailing Address - State:CA
Mailing Address - Zip Code:91767-2722
Mailing Address - Country:US
Mailing Address - Phone:909-623-6131
Mailing Address - Fax:909-865-9281
Practice Address - Street 1:2008 N GAREY AVE
Practice Address - Street 2:
Practice Address - City:POMONA
Practice Address - State:CA
Practice Address - Zip Code:91767-2722
Practice Address - Country:US
Practice Address - Phone:909-623-6131
Practice Address - Fax:909-865-9281
Is Sole Proprietor?:No
Enumeration Date:2007-02-08
Last Update Date:2015-09-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPSY 16726103TC0700X, 103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
No103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical