Individual
BRIAN WALLACE
Active
Sole proprietor
Yes
Provider details
NPI number
Gender
Man
Contact information
Practice address
239 W 9TH ST, UPLAND, CA 91786-5979
(909) 920-5102
Mailing address
762 NORTH RD, SAN BERNARDINO, CA 92404-2439
(714) 595-5314
Taxonomy
Speciality
Code
Description
License number
State
101YA0400X
Addiction (Substance Use Disorder) Counselor
Primary
—
CA
Other
Enumeration date
08/31/2022
Last updated
08/31/2022
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