Provider Demographics
NPI:1295907392
Name:WALLACE, SUSAN O'BRIEN (PSY D)
Entity type:Individual
Prefix:MRS
First Name:SUSAN
Middle Name:O'BRIEN
Last Name:WALLACE
Suffix:
Gender:F
Credentials:PSY D
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:530 S LAKE AVE # 565
Mailing Address - Street 2:
Mailing Address - City:PASADENA
Mailing Address - State:CA
Mailing Address - Zip Code:91101-3515
Mailing Address - Country:US
Mailing Address - Phone:619-665-7781
Mailing Address - Fax:
Practice Address - Street 1:1454 E 2ND ST
Practice Address - Street 2:
Practice Address - City:SAN BERNARDINO
Practice Address - State:CA
Practice Address - Zip Code:92408-0118
Practice Address - Country:US
Practice Address - Phone:909-382-7100
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-03-28
Last Update Date:2018-02-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
101YM0800X
CAPSY27744103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health