Provider Demographics
NPI:1891213393
Name:WACE, TERESA
Entity Type:Individual
Prefix:
First Name:TERESA
Middle Name:
Last Name:WACE
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:855 JEFFERSON AVENUE, #3447
Mailing Address - Street 2:
Mailing Address - City:REDWOOD CITY
Mailing Address - State:CA
Mailing Address - Zip Code:94063-9992
Mailing Address - Country:US
Mailing Address - Phone:650-542-6622
Mailing Address - Fax:
Practice Address - Street 1:1303 SAN CARLOS AVENUE
Practice Address - Street 2:
Practice Address - City:SAN CARLOS
Practice Address - State:CA
Practice Address - Zip Code:94070
Practice Address - Country:US
Practice Address - Phone:650-542-6622
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-09-05
Last Update Date:2018-10-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor