| Doctor Name: | MR. EVAN JAMES WALLACE |
| NPI Number: | 1073859351 |
| Entity Type Code: | Individual (1) |
| Gender: | M |
| Credentials: | |
| License Number: | |
| Business Practice Address: | 360 Sw 6th St Gresham, OR - 970809475 |
| Business Phone Number: | 5037263806 |
| Business Fax Number: | |
| Mailing Address: | 8915 Sw Center St., TIGARD |
| State: | OR |
| Postal Code: | 97223 |
| Phone Number: | 5037263740 |
| Fax Number: | 5037263741 |
| NPI Enumeration Date: | 12/14/2012 |
| NPI Last Update Date: | 12/14/2012 |
| 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: | |