Healthcare Provider Details

I. General information

NPI: 1053473884
Provider Name (Legal Business Name): MALCOLM LOUIS WALLACE
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/15/2006
Last Update Date: 02/02/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

982 MISSION ST
SAN FRANCISCO CA
94103-2911
US

IV. Provider business mailing address

1517 MACARTHUR BLVD 7
OAKLAND CA
94602-1264
US

V. Phone/Fax

Practice location:
  • Phone: 415-597-8000
  • Fax:
Mailing address:
  • Phone: 408-910-8252
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: