Provider Demographics
NPI:1457833428
Name:WALLACE, BRANDY RAE MARIE
Entity Type:Individual
Prefix:
First Name:BRANDY
Middle Name:RAE MARIE
Last Name:WALLACE
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2010 BULLION DR
Mailing Address - Street 2:
Mailing Address - City:TWENTYNINE PALMS
Mailing Address - State:CA
Mailing Address - Zip Code:92277-5017
Mailing Address - Country:US
Mailing Address - Phone:209-380-7932
Mailing Address - Fax:
Practice Address - Street 1:56970 YUCCA TRL STE 104
Practice Address - Street 2:
Practice Address - City:YUCCA VALLEY
Practice Address - State:CA
Practice Address - Zip Code:92284-7911
Practice Address - Country:US
Practice Address - Phone:760-369-0294
Practice Address - Fax:760-369-0295
Is Sole Proprietor?:Yes
Enumeration Date:2018-09-05
Last Update Date:2018-09-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAAMFT108839106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist