Provider Demographics
NPI:1912274473
Name:WALLACE, TAUHEEDAH SABREEN (MSSW-MFT, LAMFT)
Entity Type:Individual
Prefix:MS
First Name:TAUHEEDAH
Middle Name:SABREEN
Last Name:WALLACE
Suffix:
Gender:F
Credentials:MSSW-MFT, LAMFT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:537 E 650 S
Mailing Address - Street 2:
Mailing Address - City:OREM
Mailing Address - State:UT
Mailing Address - Zip Code:84097-6336
Mailing Address - Country:US
Mailing Address - Phone:404-422-5282
Mailing Address - Fax:
Practice Address - Street 1:750 N FREEDOM BLVD STE 300
Practice Address - Street 2:
Practice Address - City:PROVO
Practice Address - State:UT
Practice Address - Zip Code:84601-1690
Practice Address - Country:US
Practice Address - Phone:801-377-1213
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-11-28
Last Update Date:2011-11-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT7921461-3904106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist