Provider Demographics
NPI:1649852906
Name:WALLACE, ELIZABETH RACHEL (MFT)
Entity type:Individual
Prefix:PROF
First Name:ELIZABETH
Middle Name:RACHEL
Last Name:WALLACE
Suffix:
Gender:F
Credentials:MFT
Other - Prefix:MS
Other - First Name:ELIZABETH
Other - Middle Name:
Other - Last Name:WALLACE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:100 N HOWARD ST STE W
Mailing Address - Street 2:
Mailing Address - City:SPOKANE
Mailing Address - State:WA
Mailing Address - Zip Code:99201-0508
Mailing Address - Country:US
Mailing Address - Phone:478-997-2363
Mailing Address - Fax:
Practice Address - Street 1:6505 216TH ST SW STE 100
Practice Address - Street 2:
Practice Address - City:MOUNTLAKE TERRACE
Practice Address - State:WA
Practice Address - Zip Code:98043-2089
Practice Address - Country:US
Practice Address - Phone:425-640-7009
Practice Address - Fax:425-678-6455
Is Sole Proprietor?:Yes
Enumeration Date:2021-04-26
Last Update Date:2024-07-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
106H00000X
WAMG61524353106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist