Provider Demographics
NPI:1265117543
Name:WALLACE, LAUREN CATHERINE (PHD)
Entity type:Individual
Prefix:DR
First Name:LAUREN
Middle Name:CATHERINE
Last Name:WALLACE
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9 RAMSEY PL
Mailing Address - Street 2:
Mailing Address - City:STATEN ISLAND
Mailing Address - State:NY
Mailing Address - Zip Code:10304-1830
Mailing Address - Country:US
Mailing Address - Phone:347-466-3627
Mailing Address - Fax:
Practice Address - Street 1:3671 BUSINESS DR STE 110
Practice Address - Street 2:
Practice Address - City:SACRAMENTO
Practice Address - State:CA
Practice Address - Zip Code:95820-2233
Practice Address - Country:US
Practice Address - Phone:916-734-8396
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-06-15
Last Update Date:2024-09-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA33568103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical