MEDICARE: DR. TRACI L. WALLACE PH.D.

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	103T00000X	Psychologist	PSY14644	CA

General Provider Information

NPI Number	:	1881630093
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. TRACI L. WALLACE PH.D.

Provider Business Mailing Address
First Line	:	10811 WASHINGTON BLVD.
Second Line	:	SUITE 280
City	:	CULVER CITY
State	:	CA
Zip	:	90066
Country	:	US
Telephone Number	:	310-939-4297
Fax Number	:	310-745-2891

Provider Business Practice Location Address
First Line	:	10811 WASHINGTON BLVD.
Second Line	:	SUITE 280
City	:	CULVER CITY
State	:	CA
Zip	:	90066
Country	:	US
Telephone Number	:	310-939-4297
Fax Number	:	310-745-2891

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	06/22/2006
Last Update Date	:	07/08/2007

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