Provider Demographics
NPI:1710547815
Name:WALLACE, LIZA JOY
Entity Type:Individual
Prefix:
First Name:LIZA
Middle Name:JOY
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 1:3537 ALLAN ADALE CT
Mailing Address - Street 2:
Mailing Address - City:MODESTO
Mailing Address - State:CA
Mailing Address - Zip Code:95355-8200
Mailing Address - Country:US
Mailing Address - Phone:209-551-0998
Mailing Address - Fax:
Practice Address - Street 1:5501 ANTIQUE ROSE WAY
Practice Address - Street 2:
Practice Address - City:RIVERBANK
Practice Address - State:CA
Practice Address - Zip Code:95367-9505
Practice Address - Country:US
Practice Address - Phone:209-521-4791
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-06-19
Last Update Date:2019-06-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician