Provider Demographics
NPI:1700290715
Name:WALLACE, CLAIRE (MA CCC-SLP)
Entity Type:Individual
Prefix:
First Name:CLAIRE
Middle Name:
Last Name:WALLACE
Suffix:
Gender:F
Credentials:MA CCC-SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1290 SHAFFER RD APT 9304
Mailing Address - Street 2:
Mailing Address - City:SANTA CRUZ
Mailing Address - State:CA
Mailing Address - Zip Code:95060-5780
Mailing Address - Country:US
Mailing Address - Phone:831-247-9509
Mailing Address - Fax:
Practice Address - Street 1:1940 BONITA DR
Practice Address - Street 2:
Practice Address - City:APTOS
Practice Address - State:CA
Practice Address - Zip Code:95003-5524
Practice Address - Country:US
Practice Address - Phone:831-684-1804
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-06-17
Last Update Date:2014-06-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA21452235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist