Provider Demographics
NPI:1689341679
Name:WALLACE, BRUCE
Entity Type:Individual
Prefix:
First Name:BRUCE
Middle Name:
Last Name:WALLACE
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:86-226 FARRINGTON HWY
Mailing Address - Street 2:
Mailing Address - City:WAIANAE
Mailing Address - State:HI
Mailing Address - Zip Code:96792-3128
Mailing Address - Country:US
Mailing Address - Phone:808-696-9498
Mailing Address - Fax:
Practice Address - Street 1:85-888 FARRINGTON HWY
Practice Address - Street 2:
Practice Address - City:WAIANAE
Practice Address - State:HI
Practice Address - Zip Code:96792-2403
Practice Address - Country:US
Practice Address - Phone:808-696-9498
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-08-26
Last Update Date:2021-08-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health