Provider Demographics
NPI:1639297021
Name:WALLACE, MARY
Entity Type:Individual
Prefix:
First Name:MARY
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 1:225 CABRILLO HWY S
Mailing Address - Street 2:SUITE 200A
Mailing Address - City:HALF MOON BAY
Mailing Address - State:CA
Mailing Address - Zip Code:94019-8200
Mailing Address - Country:US
Mailing Address - Phone:650-573-3724
Mailing Address - Fax:650-726-4963
Practice Address - Street 1:225 CABRILLO HWY S
Practice Address - Street 2:SUITE 200A
Practice Address - City:HALF MOON BAY
Practice Address - State:CA
Practice Address - Zip Code:94019-8200
Practice Address - Country:US
Practice Address - Phone:650-573-3724
Practice Address - Fax:650-726-4963
Is Sole Proprietor?:No
Enumeration Date:2007-03-26
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAMFC31243106H00000X
CA219605163WP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Not Answered106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist
Not Answered163WP0808XNursing Service ProvidersRegistered NursePsychiatric/Mental Health