Provider Demographics
NPI:1477270676
Name:WALLACE, PAMELA JENE (BACHELORS, RADT)
Entity Type:Individual
Prefix:
First Name:PAMELA
Middle Name:JENE
Last Name:WALLACE
Suffix:
Gender:F
Credentials:BACHELORS, RADT
Other - Prefix:
Other - First Name:PAMELA
Other - Middle Name:JENE
Other - Last Name:MURRAY
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:NONE
Mailing Address - Street 1:1331 W AVENUE J STE 103
Mailing Address - Street 2:
Mailing Address - City:LANCASTER
Mailing Address - State:CA
Mailing Address - Zip Code:93534-2946
Mailing Address - Country:US
Mailing Address - Phone:661-579-3191
Mailing Address - Fax:661-522-3130
Practice Address - Street 1:1331 W AVENUE J STE 103
Practice Address - Street 2:
Practice Address - City:LANCASTER
Practice Address - State:CA
Practice Address - Zip Code:93534-2946
Practice Address - Country:US
Practice Address - Phone:661-579-3191
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-10-27
Last Update Date:2022-10-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAR1465460422101YS0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YS0200XBehavioral Health & Social Service ProvidersCounselorSchool