Healthcare Provider Details

I. General information

NPI: 1205381787
Provider Name (Legal Business Name): DIERDRE WALLACE
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/24/2016
Last Update Date: 04/10/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3800 COOLIDGE AVE
OAKLAND CA
94602-3311
US

IV. Provider business mailing address

2326 FRUITVALE AVE
OAKLAND CA
94601-2534
US

V. Phone/Fax

Practice location:
  • Phone: 510-482-2244
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number StateNULL
# 2
Primary TaxonomyY
Taxonomy Code106H00000X
TaxonomyMarriage & Family Therapist
License Number
License Number StateNULL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: