Provider Demographics
NPI:1629462718
Name:WALLACE, MARGARET
Entity Type:Individual
Prefix:
First Name:MARGARET
Middle Name:
Last Name:WALLACE
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5457 LAUREL CANYON BLVD APT 206
Mailing Address - Street 2:
Mailing Address - City:VALLEY VILLAGE
Mailing Address - State:CA
Mailing Address - Zip Code:91607-2191
Mailing Address - Country:US
Mailing Address - Phone:323-947-5826
Mailing Address - Fax:
Practice Address - Street 1:18344 CLARK ST STE 205
Practice Address - Street 2:
Practice Address - City:TARZANA
Practice Address - State:CA
Practice Address - Zip Code:91356-3575
Practice Address - Country:US
Practice Address - Phone:323-947-5826
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-03-26
Last Update Date:2020-09-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA102949106H00000X
CAMFTI79653106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist