Healthcare Provider Details

I. General information

NPI: 1124215256
Provider Name (Legal Business Name): SUSAN 'SUZI' WALLACE PSYCHOLOGIST
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/03/2007
Last Update Date: 06/09/2026
Certification Date: 06/09/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4341 TUDOR CENTRE DR STE 300
ANCHORAGE AK
99508-5904
US

IV. Provider business mailing address

7033 E TUDOR RD
ANCHORAGE AK
99507-1262
US

V. Phone/Fax

Practice location:
  • Phone: 907-729-2500
  • Fax:
Mailing address:
  • Phone: 907-729-6801
  • Fax: 907-729-5180

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License NumberA0510074
License Number StateAR
# 2
Primary TaxonomyN
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License Number18-08P
License Number StateAR
# 3
Primary TaxonomyY
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License Number242882
License Number StateAK
# 4
Primary TaxonomyN
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number1724
License Number StateAR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: