=====================================================
General NPI Number Information
=====================================================
NPI Number | 1770636367
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | KATHLEEN M. WALLACE PSY.D
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 01/19/2007
-----------------------------------------------------
Last Update Date | 09/15/2025
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 3400 WARREN-SHARON ROAD
-----------------------------------------------------
City | VIENNA
-----------------------------------------------------
State | OH
-----------------------------------------------------
Zip | 44473-9532
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 330-720-5786
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 3438 WARREN SHARON RD
-----------------------------------------------------
City | VIENNA
-----------------------------------------------------
State | OH
-----------------------------------------------------
Zip | 44473-9532
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 330-720-5786
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 103TC0700X
-----------------------------------------------------
Taxonomy Name | Clinical Psychologist
-----------------------------------------------------
License Number | PS015630
-----------------------------------------------------
License Number State | PA
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 103TC0700X
-----------------------------------------------------
Taxonomy Name | Clinical Psychologist
-----------------------------------------------------
License Number | 4820
-----------------------------------------------------
License Number State | OH
-----------------------------------------------------