Basic Information
| Provider Information | |||||||||
| NPI: | 1053473884 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | WALLACE | ||||||||
| FirstName: | MALCOLM | ||||||||
| MiddleName: | LOUIS | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1517 MACARTHUR BLVD | ||||||||
| Address2: | 7 | ||||||||
| City: | OAKLAND | ||||||||
| State: | CA | ||||||||
| PostalCode: | 946021264 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4089108252 | ||||||||
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| Practice Location | |||||||||
| Address1: | 982 MISSION ST | ||||||||
| Address2: | |||||||||
| City: | SAN FRANCISCO | ||||||||
| State: | CA | ||||||||
| PostalCode: | 941032911 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4155978000 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 12/15/2006 | ||||||||
| LastUpdateDate: | 02/02/2016 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101YM0800X | Y | Behavioral Health & Social Service Providers | Counselor | Mental Health |
No ID Information.