Provider Demographics
NPI:1891190831
Name:WALLACE, KATHERINE LUCAS
Entity Type:Individual
Prefix:
First Name:KATHERINE
Middle Name:LUCAS
Last Name:WALLACE
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:KASEY
Other - Middle Name:
Other - Last Name:WALLACE
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:3800 COOLIDGE AVE
Mailing Address - Street 2:
Mailing Address - City:OAKLAND
Mailing Address - State:CA
Mailing Address - Zip Code:94602-3311
Mailing Address - Country:US
Mailing Address - Phone:510-482-2244
Mailing Address - Fax:510-842-0406
Practice Address - Street 1:3800 COOLIDGE AVE
Practice Address - Street 2:
Practice Address - City:OAKLAND
Practice Address - State:CA
Practice Address - Zip Code:94602-3311
Practice Address - Country:US
Practice Address - Phone:510-482-2244
Practice Address - Fax:510-842-0406
Is Sole Proprietor?:Yes
Enumeration Date:2014-11-04
Last Update Date:2014-11-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAIMF82518106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist