Provider Demographics
NPI:1013143262
Name:WALLACE, IAN JOSEPH (PHD)
Entity Type:Individual
Prefix:DR
First Name:IAN
Middle Name:JOSEPH
Last Name:WALLACE
Suffix:
Gender:M
Credentials:PHD
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Mailing Address - Street 1:200 MARITIME ACADEMY DR
Mailing Address - Street 2:THE CALIFORNIA MARITIME ACADEMY, STUDENT HEALTH SERVICE
Mailing Address - City:VALLEJO
Mailing Address - State:CA
Mailing Address - Zip Code:94590-8181
Mailing Address - Country:US
Mailing Address - Phone:707-654-1170
Mailing Address - Fax:707-654-1171
Practice Address - Street 1:200 MARITIME ACADEMY DR
Practice Address - Street 2:THE CALIFORNIA MARITIME ACADEMY, STUDENT HEALTH SERVICE
Practice Address - City:VALLEJO
Practice Address - State:CA
Practice Address - Zip Code:94590-8181
Practice Address - Country:US
Practice Address - Phone:707-654-1170
Practice Address - Fax:707-654-1171
Is Sole Proprietor?:No
Enumeration Date:2009-06-02
Last Update Date:2013-07-23
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
CAPSY# 23646103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist