Provider Demographics
NPI:1750988127
Name:WALLACE, STEPHANIE (LMFT)
Entity type:Individual
Prefix:
First Name:STEPHANIE
Middle Name:
Last Name:WALLACE
Suffix:
Gender:F
Credentials:LMFT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8442 VIA SONOMA UNIT 81
Mailing Address - Street 2:
Mailing Address - City:LA JOLLA
Mailing Address - State:CA
Mailing Address - Zip Code:92037-2725
Mailing Address - Country:US
Mailing Address - Phone:303-590-8221
Mailing Address - Fax:
Practice Address - Street 1:409 CAMINO DEL RIO S STE 300
Practice Address - Street 2:
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92108-3507
Practice Address - Country:US
Practice Address - Phone:858-215-4920
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-10-07
Last Update Date:2025-03-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA143378106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family TherapistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA106H00000XMedicaid