Provider Demographics
NPI:1811313018
Name:GARCIA, WALLACE B (MMHC)
Entity type:Individual
Prefix:
First Name:WALLACE
Middle Name:B
Last Name:GARCIA
Suffix:
Gender:M
Credentials:MMHC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:#2P38 CALLE 41
Mailing Address - Street 2:URB. METROPOLIS
Mailing Address - City:CAROLINA
Mailing Address - State:PR
Mailing Address - Zip Code:00987-0000
Mailing Address - Country:US
Mailing Address - Phone:787-667-6123
Mailing Address - Fax:
Practice Address - Street 1:#2P38 CALLE 41
Practice Address - Street 2:URB. METROPOLIS
Practice Address - City:CAROLINA
Practice Address - State:PR
Practice Address - Zip Code:00987-0000
Practice Address - Country:US
Practice Address - Phone:787-667-6123
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-03-12
Last Update Date:2014-03-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PR2148101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional