MEDICARE: ANGELA K WALLACE, MFT

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	106H00000X	Marriage & Family Therapist	45450	CA

General Provider Information

NPI Number	:	1629460274
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	ANGELA K WALLACE, MFT

Provider Business Mailing Address
First Line	:	554 S SAN VICENTE BLVD STE 200
Second Line	:
City	:	LOS ANGELES
State	:	CA
Zip	:	90048-4651
Country	:	US
Telephone Number	:	323-270-5437
Fax Number	:

Provider Business Practice Location Address
First Line	:	554 S SAN VICENTE BLVD STE 200
Second Line	:
City	:	LOS ANGELES
State	:	CA
Zip	:	90048-4651
Country	:	US
Telephone Number	:	323-270-5437
Fax Number	:

Authorized Official
Title or Position	:	PSYCHOTHERAPIST
Name	:	MS. ANGELA K WALLACE
Credential	:	LMFT
Telephone Number	:	323-270-5437

Provider Enumeration Date	:	02/19/2015
Last Update Date	:	02/19/2015

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