Healthcare Provider Details

I. General information

NPI: 1508417916
Provider Name (Legal Business Name): CASSANDRA D PASQUARIELLO WALLACE PHD, MS, EDM, CMPC
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

Provider Other Name: MRS. CASSANDRA DEMETRIA PASQUARIELLO

II. Dates (important events)

Enumeration Date: 09/26/2019
Last Update Date: 08/21/2026
Certification Date: 08/21/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2475 JEFFERSON ST APT 104
CARLSBAD CA
92008-1413
US

IV. Provider business mailing address

PO BOX 102
CARLSBAD CA
92018-0102
US

V. Phone/Fax

Practice location:
  • Phone: 707-227-8511
  • Fax:
Mailing address:
  • Phone: 707-227-8511
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code103TC1900X
TaxonomyCounseling Psychologist
License Number4439
License Number StateCT
# 2
Primary TaxonomyN
Taxonomy Code103TC1900X
TaxonomyCounseling Psychologist
License NumberPSY-005761
License Number StateAZ
# 3
Primary TaxonomyY
Taxonomy Code103TC1900X
TaxonomyCounseling Psychologist
License NumberPSY26752
License Number StateCA
# 4
Primary TaxonomyN
Taxonomy Code103TC1900X
TaxonomyCounseling Psychologist
License Number3669-57
License Number StateWI
# 5
Primary TaxonomyN
Taxonomy Code103TC1900X
TaxonomyCounseling Psychologist
License NumberPY60534188
License Number StateWA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: