Provider Demographics
NPI:1770636367
Name:WALLACE, KATHLEEN M (PSYD)
Entity Type:Individual
Prefix:DR
First Name:KATHLEEN
Middle Name:M
Last Name:WALLACE
Suffix:
Gender:F
Credentials:PSYD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3438 WARREN SHARON RD
Mailing Address - Street 2:
Mailing Address - City:VIENNA
Mailing Address - State:OH
Mailing Address - Zip Code:44473-9532
Mailing Address - Country:US
Mailing Address - Phone:330-720-5786
Mailing Address - Fax:
Practice Address - Street 1:3400 WARREN-SHARON ROAD
Practice Address - Street 2:
Practice Address - City:VIENNA,
Practice Address - State:OH
Practice Address - Zip Code:44473-9532
Practice Address - Country:US
Practice Address - Phone:330-720-5786
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-19
Last Update Date:2015-03-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH4820103TC0700X
PAPS015630103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
7412444OtherAETNA
000000867501OtherANTHEM BLUE CROSS BLUE SHIELD
OH0213754Medicaid
PA102574943Medicaid
175402OtherMHNET
PA001947342OtherHIGHMARK BLUE SHIELD
1044444OtherCIGNA
251830792OtherMULTIPLAN PHCS
7412444OtherAETNA