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General NPI Number Information
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NPI Number | 1750988127
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Entity Type | Individual
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Provider Name | STEPHANIE WALLACE LMFT
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Gender | Female
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Dates
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Enumeration Date | 10/07/2020
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Last Update Date | 03/23/2025
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Provider Practice Location Address
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Address Line | 409 CAMINO DEL RIO S STE 300
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City | SAN DIEGO
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State | CA
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Zip | 92108-3507
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Country | US
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Telephone | 858-215-4920
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Fax |
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Provider Business Mailing Address
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Address Line | 8442 VIA SONOMA UNIT 81
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City | LA JOLLA
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State | CA
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Zip | 92037-2725
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Country | US
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Telephone | 303-590-8221
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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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 | 143378
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License Number State | CA
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