Provider Demographics
NPI:1366599334
Name:WALLACE, MAUREEN (LCSW)
Entity type:Individual
Prefix:
First Name:MAUREEN
Middle Name:
Last Name:WALLACE
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5580 DEER RUN DRIVE
Mailing Address - Street 2:
Mailing Address - City:RICHMOND
Mailing Address - State:CA
Mailing Address - Zip Code:94803-3870
Mailing Address - Country:US
Mailing Address - Phone:510-367-9818
Mailing Address - Fax:
Practice Address - Street 1:919 VILLAGE CENTER
Practice Address - Street 2:STE 7
Practice Address - City:LAFAYETTE
Practice Address - State:CA
Practice Address - Zip Code:94549-3599
Practice Address - Country:US
Practice Address - Phone:925-283-2610
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-01-04
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CALC85211041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical