Provider Demographics
NPI:1881630093
Name:WALLACE, TRACI L (PHD)
Entity Type:Individual
Prefix:DR
First Name:TRACI
Middle Name:L
Last Name:WALLACE
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10811 WASHINGTON BLVD.
Mailing Address - Street 2:SUITE 280
Mailing Address - City:CULVER CITY
Mailing Address - State:CA
Mailing Address - Zip Code:90066
Mailing Address - Country:US
Mailing Address - Phone:310-939-4297
Mailing Address - Fax:310-745-2891
Practice Address - Street 1:10811 WASHINGTON BLVD.
Practice Address - Street 2:SUITE 280
Practice Address - City:CULVER CITY
Practice Address - State:CA
Practice Address - Zip Code:90066
Practice Address - Country:US
Practice Address - Phone:310-939-4297
Practice Address - Fax:310-745-2891
Is Sole Proprietor?:No
Enumeration Date:2006-06-22
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPSY14644103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist