Doctor Name: | MARIE RENEE WALLACE |
NPI Number: | 1033591045 |
Entity Type Code: | Individual (1) |
Gender: | F |
Credentials: | |
License Number: | |
Business Practice Address: | 7204 Skyway Paradise, CA - 959693280 |
Business Phone Number: | 5308771965 |
Business Fax Number: | 5308945791 |
Mailing Address: | 7204 Skyway, PARADISE |
State: | CA |
Postal Code: | 959693280 |
Phone Number: | 5308771965 |
Fax Number: | 5308945791 |
NPI Enumeration Date: | 06/25/2015 |
NPI Last Update Date: | 06/25/2015 |
Replacement NPI: | 0 |
NPI Deactivation Date: | |
NPI Reactivation Date: |
Taxonomy Information: | |
Healthcare Provider Taxonomy: | 101YM0800X |
License Number: | |
Healthcare Provider Taxonomy: (Secondary) | Y |
State: | |
Taxonomy Type: | Behavioral Health & Social Service Providers |
Taxonomy Classification: | Counselor |
Taxonomy Specialization: | Mental Health |
Taxonomy Definition: |