Provider Demographics
NPI:1538295142
Name:WALLACE, TREVOR B (MFTI/IMF)
Entity Type:Individual
Prefix:MR
First Name:TREVOR
Middle Name:B
Last Name:WALLACE
Suffix:
Gender:M
Credentials:MFTI/IMF
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6833 STOCKTON BLVD
Mailing Address - Street 2:STE 485
Mailing Address - City:SACRAMENTO
Mailing Address - State:CA
Mailing Address - Zip Code:95823-2372
Mailing Address - Country:US
Mailing Address - Phone:916-394-0800
Mailing Address - Fax:
Practice Address - Street 1:6833 STOCKTON BLVD
Practice Address - Street 2:STE 485
Practice Address - City:SACRAMENTO
Practice Address - State:CA
Practice Address - Zip Code:95823-2372
Practice Address - Country:US
Practice Address - Phone:916-394-0800
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-02-26
Last Update Date:2012-04-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA70088106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist