Healthcare Provider Details

I. General information

NPI: 1912274473
Provider Name (Legal Business Name): TAUHEEDAH SABREEN WALLACE MSSW-MFT, LAMFT
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/28/2011
Last Update Date: 11/28/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

750 N FREEDOM BLVD STE 300
PROVO UT
84601-1690
US

IV. Provider business mailing address

537 E 650 S
OREM UT
84097-6336
US

V. Phone/Fax

Practice location:
  • Phone: 801-377-1213
  • Fax:
Mailing address:
  • Phone: 404-422-5282
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code106H00000X
TaxonomyMarriage & Family Therapist
License Number7921461-3904
License Number StateUT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: