=====================================================
General NPI Number Information
=====================================================
NPI Number | 1215398722
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | PATRICIA WALLACE PSYD, LMFT
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 03/10/2016
-----------------------------------------------------
Last Update Date | 07/01/2021
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 864 S ROBERTSON BLVD STE 103
-----------------------------------------------------
City | LOS ANGELES
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 90035-1622
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 818-732-6660
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 10231 RIVERSIDE DR APT 306
-----------------------------------------------------
City | TOLUCA LAKE
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 91602-2559
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 310-930-3332
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 106H00000X
-----------------------------------------------------
Taxonomy Name | Marriage & Family Therapist
-----------------------------------------------------
License Number | 113122
-----------------------------------------------------
License Number State | CA
-----------------------------------------------------