Provider Demographics
NPI:1487075271
Name:WALLACE, VICTORIA LEE
Entity type:Individual
Prefix:
First Name:VICTORIA
Middle Name:LEE
Last Name:WALLACE
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:VICTORIA
Other - Middle Name:LEE
Other - Last Name:ROMUALDO
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:1314 VICTORIA ST
Mailing Address - Street 2:APT. #1002
Mailing Address - City:HONOLULU
Mailing Address - State:HI
Mailing Address - Zip Code:96814-1048
Mailing Address - Country:US
Mailing Address - Phone:808-675-6200
Mailing Address - Fax:
Practice Address - Street 1:1314 VICTORIA ST
Practice Address - Street 2:APT. 1002
Practice Address - City:HONOLULU
Practice Address - State:HI
Practice Address - Zip Code:96814-1048
Practice Address - Country:US
Practice Address - Phone:808-675-6200
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-12-20
Last Update Date:2013-12-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
HI1874104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker