Healthcare Provider Details

I. General information

NPI: 1992199889
Provider Name (Legal Business Name): MARILYN WALLACE LMFT
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/27/2015
Last Update Date: 03/27/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3333 SKYPARK DR STE 220
TORRANCE CA
90505-5035
US

IV. Provider business mailing address

3333 SKYPARK DR STE 220
TORRANCE CA
90505-5035
US

V. Phone/Fax

Practice location:
  • Phone: 310-257-5750
  • Fax:
Mailing address:
  • Phone: 310-257-5750
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code106H00000X
TaxonomyMarriage & Family Therapist
License Number38472
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: