Provider Demographics
NPI:1912031311
Name:WALLACE, REBECCA B (MFT)
Entity Type:Individual
Prefix:MRS
First Name:REBECCA
Middle Name:B
Last Name:WALLACE
Suffix:
Gender:F
Credentials:MFT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2422 FAIRMONT AVE
Mailing Address - Street 2:
Mailing Address - City:SANTA ANA
Mailing Address - State:CA
Mailing Address - Zip Code:92706-2010
Mailing Address - Country:US
Mailing Address - Phone:714-680-9082
Mailing Address - Fax:714-680-8235
Practice Address - Street 1:801 E CHAPMAN AVE
Practice Address - Street 2:
Practice Address - City:FULLERTON
Practice Address - State:CA
Practice Address - Zip Code:92831-3839
Practice Address - Country:US
Practice Address - Phone:714-680-9082
Practice Address - Fax:714-680-8235
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-15
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAMFC8969106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist