Healthcare Provider Details

I. General information

NPI: 1871407197
Provider Name (Legal Business Name): T WACE
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/01/2026
Last Update Date: 10/01/2026
Certification Date: 10/01/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1313 LAUREL ST STE 224D
SAN CARLOS CA
94070-5043
US

IV. Provider business mailing address

2905 SE 170TH AVE
VANCOUVER WA
98683-2325
US

V. Phone/Fax

Practice location:
  • Phone: 650-542-6622
  • Fax: 650-332-0283
Mailing address:
  • Phone: 650-542-6622
  • Fax: 650-332-0283

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101Y00000X
TaxonomyCounselor
License Number
License Number StateNULL

VIII. Authorized Official

Name: TERESA WACE
Title or Position: CEO
Credential: LMFT, LPCC
Phone: 650-542-6622