Provider Demographics
NPI:1649069964
Name:WALLACE, CHANDRA MARIE
Entity type:Individual
Prefix:
First Name:CHANDRA
Middle Name:MARIE
Last Name:WALLACE
Suffix:
Gender:
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7610 40TH ST W STE 300
Mailing Address - Street 2:
Mailing Address - City:UNIVERSITY PLACE
Mailing Address - State:WA
Mailing Address - Zip Code:98466-3834
Mailing Address - Country:US
Mailing Address - Phone:253-830-6242
Mailing Address - Fax:
Practice Address - Street 1:7610 40TH ST W STE 300
Practice Address - Street 2:
Practice Address - City:UNIVERSITY PLACE
Practice Address - State:WA
Practice Address - Zip Code:98466-3834
Practice Address - Country:US
Practice Address - Phone:253-830-6242
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2025-05-02
Last Update Date:2025-05-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor