Provider Demographics
NPI:1609057389
Name:WALLACE, SHARMILA RAEVETTE (BA)
Entity Type:Individual
Prefix:MS
First Name:SHARMILA
Middle Name:RAEVETTE
Last Name:WALLACE
Suffix:
Gender:F
Credentials:BA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5425 HOLLAND ST APT 3
Mailing Address - Street 2:
Mailing Address - City:OAKLAND
Mailing Address - State:CA
Mailing Address - Zip Code:94601-5742
Mailing Address - Country:US
Mailing Address - Phone:510-533-3627
Mailing Address - Fax:
Practice Address - Street 1:5425 HOLLAND ST APT 3
Practice Address - Street 2:
Practice Address - City:OAKLAND
Practice Address - State:CA
Practice Address - Zip Code:94601-5742
Practice Address - Country:US
Practice Address - Phone:510-533-3627
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-11-21
Last Update Date:2007-11-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TF0200XBehavioral Health & Social Service ProvidersPsychologistForensic