Provider Demographics
NPI:1497226229
Name:WALLACE, EVAN BARRINGTON (RADT)
Entity Type:Individual
Prefix:
First Name:EVAN
Middle Name:BARRINGTON
Last Name:WALLACE
Suffix:
Gender:M
Credentials:RADT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2980 CEDAR ST
Mailing Address - Street 2:
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92102-1515
Mailing Address - Country:US
Mailing Address - Phone:619-260-1605
Mailing Address - Fax:619-239-1817
Practice Address - Street 1:2980 CEDAR ST
Practice Address - Street 2:
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92102-1515
Practice Address - Country:US
Practice Address - Phone:619-260-7370
Practice Address - Fax:619-239-1817
Is Sole Proprietor?:No
Enumeration Date:2018-12-05
Last Update Date:2018-12-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAR1321750918101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)