Provider Demographics
NPI:1750674388
Name:WALLACE, DIVIER J (MA/MFTI)
Entity Type:Individual
Prefix:MR
First Name:DIVIER
Middle Name:J
Last Name:WALLACE
Suffix:
Gender:M
Credentials:MA/MFTI
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:400 ESTUDILLO AVE STE 100
Mailing Address - Street 2:
Mailing Address - City:SAN LEANDRO
Mailing Address - State:CA
Mailing Address - Zip Code:94577-4962
Mailing Address - Country:US
Mailing Address - Phone:510-924-0548
Mailing Address - Fax:
Practice Address - Street 1:400 ESTUDILLO AVE STE 100
Practice Address - Street 2:
Practice Address - City:SAN LEANDRO
Practice Address - State:CA
Practice Address - Zip Code:94577-4962
Practice Address - Country:US
Practice Address - Phone:510-924-0548
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-05-16
Last Update Date:2021-06-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
171M00000X, 101Y00000X
CA61914106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor
No171M00000XOther Service ProvidersCase Manager/Care Coordinator
No106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist