Individual
ANGELA KATHLEEN WALLACE
Active
Sole proprietor
Yes
Provider details
NPI number
Gender
F
Credential
MFT #45450
Contact information
Practice address
554 S SAN VICENTE BLVD STE 200, LOS ANGELES, CA 90048-4651
(310) 862-4668
Mailing address
554 S SAN VICENTE BLVD STE 200, LOS ANGELES, CA 90048-4651
(310) 862-4668
Taxonomy
Speciality
Code
Description
License number
State
106H00000X
Marriage & Family Therapist
Primary
45450
CA
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
1629460274
TYPE 2 NPI
CA
Enumeration date
03/28/2018
Last updated
03/28/2018
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