Healthcare Provider Details

I. General information

NPI: 1619370798
Provider Name (Legal Business Name): THERESA ANNE WALLACE
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/02/2014
Last Update Date: 01/13/2022
Certification Date: 01/13/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1231 E DYER RD STE 135
SANTA ANA CA
92705-5643
US

IV. Provider business mailing address

PO BOX 12
PLACENTIA CA
92871-0012
US

V. Phone/Fax

Practice location:
  • Phone: 949-250-0488
  • Fax: 714-540-1908
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number94659
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: