MEDICARE: ANGELA KATHLEEN WALLACE MFT #45450

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	106H00000X	Marriage & Family Therapist	45450	CA

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	1629460274	OTHER	CA	TYPE 2 NPI

General Provider Information

NPI Number	:	1417452731
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	ANGELA KATHLEEN WALLACE MFT #45450

Provider Business Mailing Address
First Line	:	554 S SAN VICENTE BLVD STE 200
Second Line	:
City	:	LOS ANGELES
State	:	CA
Zip	:	90048-4651
Country	:	US
Telephone Number	:	310-862-4668
Fax Number	:

Provider Business Practice Location Address
First Line	:	554 S SAN VICENTE BLVD STE 200
Second Line	:
City	:	LOS ANGELES
State	:	CA
Zip	:	90048-4651
Country	:	US
Telephone Number	:	310-862-4668
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	03/28/2018
Last Update Date	:	03/28/2018

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