Provider Demographics
NPI:1477632081
Name:WALLACE, KRIS ELAINE (LMFT)
Entity Type:Individual
Prefix:MRS
First Name:KRIS
Middle Name:ELAINE
Last Name:WALLACE
Suffix:
Gender:F
Credentials:LMFT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3133 N MILLBROOK AVE
Mailing Address - Street 2:
Mailing Address - City:FRESNO
Mailing Address - State:CA
Mailing Address - Zip Code:93703-1425
Mailing Address - Country:US
Mailing Address - Phone:559-435-8918
Mailing Address - Fax:
Practice Address - Street 1:3133 N MILLBROOK AVE
Practice Address - Street 2:
Practice Address - City:FRESNO
Practice Address - State:CA
Practice Address - Zip Code:93703-1425
Practice Address - Country:US
Practice Address - Phone:559-435-8918
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-11-03
Last Update Date:2008-09-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAMFC36336106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA106H00000XMedicare ID - Type UnspecifiedLICENSED MARRIAGE & FAMIL