Provider Demographics
NPI:1710105911
Name:WALLACE, RICHARD FRANKLIN (MFT)
Entity Type:Individual
Prefix:MR
First Name:RICHARD
Middle Name:FRANKLIN
Last Name:WALLACE
Suffix:
Gender:M
Credentials:MFT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3341 M ST
Mailing Address - Street 2:
Mailing Address - City:MERCED
Mailing Address - State:CA
Mailing Address - Zip Code:95348-2714
Mailing Address - Country:US
Mailing Address - Phone:209-722-8062
Mailing Address - Fax:209-722-8064
Practice Address - Street 1:3341 M ST
Practice Address - Street 2:
Practice Address - City:MERCED
Practice Address - State:CA
Practice Address - Zip Code:95348-2714
Practice Address - Country:US
Practice Address - Phone:209-722-8062
Practice Address - Fax:209-722-8064
Is Sole Proprietor?:Yes
Enumeration Date:2007-04-23
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA13005106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist