Provider Demographics
NPI:1447553300
Name:WALLACE, PATRICIA A (CATC)
Entity type:Individual
Prefix:
First Name:PATRICIA
Middle Name:A
Last Name:WALLACE
Suffix:
Gender:F
Credentials:CATC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:450 ROSEWOOD AVE
Mailing Address - Street 2:SUITE215
Mailing Address - City:CAMARILLO
Mailing Address - State:CA
Mailing Address - Zip Code:93010-5914
Mailing Address - Country:US
Mailing Address - Phone:805-482-1265
Mailing Address - Fax:805-389-5295
Practice Address - Street 1:450 ROSEWOOD AVE
Practice Address - Street 2:SUITE215
Practice Address - City:CAMARILLO
Practice Address - State:CA
Practice Address - Zip Code:93010-5914
Practice Address - Country:US
Practice Address - Phone:805-482-1265
Practice Address - Fax:805-389-5295
Is Sole Proprietor?:No
Enumeration Date:2010-12-15
Last Update Date:2010-12-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA040970101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)