Provider Demographics
NPI:1699367482
Name:WALLACE, BARBARA
Entity Type:Individual
Prefix:
First Name:BARBARA
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 1:11227 VALLEY BLVD
Mailing Address - Street 2:
Mailing Address - City:EL MONTE
Mailing Address - State:CA
Mailing Address - Zip Code:91731-3299
Mailing Address - Country:US
Mailing Address - Phone:626-444-0705
Mailing Address - Fax:626-444-0710
Practice Address - Street 1:11227 VALLEY BLVD
Practice Address - Street 2:
Practice Address - City:EL MONTE
Practice Address - State:CA
Practice Address - Zip Code:91731-3299
Practice Address - Country:US
Practice Address - Phone:626-444-0705
Practice Address - Fax:626-444-0710
Is Sole Proprietor?:No
Enumeration Date:2021-02-03
Last Update Date:2021-02-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CARH0003581119101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)