Provider Demographics
NPI:1477320174
Name:WALLACE, MANUEL PARKER (SUD I)
Entity Type:Individual
Prefix:MR
First Name:MANUEL
Middle Name:PARKER
Last Name:WALLACE
Suffix:
Gender:M
Credentials:SUD I
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2150 N VICTORIA AVE
Mailing Address - Street 2:
Mailing Address - City:OXNARD
Mailing Address - State:CA
Mailing Address - Zip Code:93036-7791
Mailing Address - Country:US
Mailing Address - Phone:805-382-6296
Mailing Address - Fax:805-382-9487
Practice Address - Street 1:2150 N VICTORIA AVE
Practice Address - Street 2:
Practice Address - City:OXNARD
Practice Address - State:CA
Practice Address - Zip Code:93036-7791
Practice Address - Country:US
Practice Address - Phone:805-382-6296
Practice Address - Fax:805-382-9487
Is Sole Proprietor?:No
Enumeration Date:2023-12-04
Last Update Date:2024-01-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)