Provider Demographics
NPI:1902844244
Name:WALLACH, DONALD M (MFT)
Entity Type:Individual
Prefix:
First Name:DONALD
Middle Name:M
Last Name:WALLACH
Suffix:
Gender:M
Credentials:MFT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:222 WELLER ST STE 205
Mailing Address - Street 2:
Mailing Address - City:PETALUMA
Mailing Address - State:CA
Mailing Address - Zip Code:94952-7107
Mailing Address - Country:US
Mailing Address - Phone:707-583-2305
Mailing Address - Fax:
Practice Address - Street 1:222 WELLER ST STE 205
Practice Address - Street 2:
Practice Address - City:PETALUMA
Practice Address - State:CA
Practice Address - Zip Code:94952-7107
Practice Address - Country:US
Practice Address - Phone:707-583-2305
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-06-02
Last Update Date:2012-03-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA34379106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist