Basic Information
Provider Information | |||||||||
NPI: | 1427199157 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | WALLACE-BURKE | ||||||||
FirstName: | PATRICIA | ||||||||
MiddleName: | FAYE | ||||||||
NamePrefix: | DR. | ||||||||
NameSuffix: |   | ||||||||
Credential: | PH.D. | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: | WALLACE | ||||||||
OtherFirstName: | PATRICIA | ||||||||
OtherMiddleName: | FAYE | ||||||||
OtherNamePrefix: | DR. | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: | PH.D. | ||||||||
OtherLastNameType: | 5 | ||||||||
Mailing Information | |||||||||
Address1: | 2008 N GAREY AVE | ||||||||
Address2: |   | ||||||||
City: | POMONA | ||||||||
State: | CA | ||||||||
PostalCode: | 917672722 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 9096236131 | ||||||||
FaxNumber: | 9098659281 | ||||||||
Practice Location | |||||||||
Address1: | 2008 N GAREY AVE | ||||||||
Address2: |   | ||||||||
City: | POMONA | ||||||||
State: | CA | ||||||||
PostalCode: | 917672722 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 9096236131 | ||||||||
FaxNumber: | 9098659281 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 02/08/2007 | ||||||||
LastUpdateDate: | 09/01/2015 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | F | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 103TC0700X | PSY 16726 | CA | N |   | Behavioral Health & Social Service Providers | Psychologist | Clinical | 103T00000X | PSY 16726 | CA | Y |   | Behavioral Health & Social Service Providers | Psychologist |   |
No ID Information.