Healthcare Provider Details

I. General information

NPI: 1174015499
Provider Name (Legal Business Name): DAVID WALLACE M.S. CCC-SLP
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/01/2018
Last Update Date: 08/30/2023
Certification Date: 08/30/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4850 NATOMAS BLVD APT 127M
SACRAMENTO CA
95835-1266
US

IV. Provider business mailing address

4850 NATOMAS BLVD APT 127M
SACRAMENTO CA
95835-1266
US

V. Phone/Fax

Practice location:
  • Phone: 209-479-9966
  • Fax:
Mailing address:
  • Phone: 209-479-9966
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2355S0801X
TaxonomySpeech-Language Assistant
License Number3499
License Number StateCA
# 2
Primary TaxonomyY
Taxonomy Code235Z00000X
TaxonomySpeech-Language Pathologist
License Number32521
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: