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General NPI Number Information
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NPI Number | 1629460274
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Entity Type | Organization
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Legal Business Name | ANGELA K WALLACE, MFT
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Dates
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Enumeration Date | 02/19/2015
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Last Update Date | 02/19/2015
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Provider Practice Location Address
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Address Line | 554 S SAN VICENTE BLVD STE 200
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City | LOS ANGELES
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State | CA
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Zip | 90048-4651
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Country | US
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Telephone | 323-270-5437
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Fax |
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Provider Business Mailing Address
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Address Line | 554 S SAN VICENTE BLVD STE 200
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City | LOS ANGELES
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State | CA
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Zip | 90048-4651
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Country | US
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Telephone | 323-270-5437
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Fax |
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Authorized Official
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Title or Position | PSYCHOTHERAPIST
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Name | MS. ANGELA K WALLACE
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Credential | LMFT
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Telephone | 323-270-5437
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 106H00000X
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Taxonomy Name | Marriage & Family Therapist
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License Number | 45450
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License Number State | CA
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