Provider Demographics
NPI:1720580699
Name:WALLACE, DAWN M (CCC-SLP)
Entity Type:Individual
Prefix:MRS
First Name:DAWN
Middle Name:M
Last Name:WALLACE
Suffix:
Gender:F
Credentials:CCC-SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:181 SAND CREEK RD STE A
Mailing Address - Street 2:
Mailing Address - City:BRENTWOOD
Mailing Address - State:CA
Mailing Address - Zip Code:94513-2209
Mailing Address - Country:US
Mailing Address - Phone:925-626-7152
Mailing Address - Fax:
Practice Address - Street 1:181 SAND CREEK RD STE A
Practice Address - Street 2:
Practice Address - City:BRENTWOOD
Practice Address - State:CA
Practice Address - Zip Code:94513-2209
Practice Address - Country:US
Practice Address - Phone:925-626-7152
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-03-06
Last Update Date:2018-12-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist