Healthcare Provider Details

I. General information

NPI: 1770636367
Provider Name (Legal Business Name): KATHLEEN M. WALLACE PSY.D
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/19/2007
Last Update Date: 09/15/2025
Certification Date: 09/15/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3400 WARREN-SHARON ROAD
VIENNA OH
44473-9532
US

IV. Provider business mailing address

3438 WARREN SHARON RD
VIENNA OH
44473-9532
US

V. Phone/Fax

Practice location:
  • Phone: 330-720-5786
  • Fax:
Mailing address:
  • Phone: 330-720-5786
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License NumberPS015630
License Number StatePA
# 2
Primary TaxonomyN
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License Number4820
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: