Individual
AYESHA WALLACE
Active
Sole proprietor
No
Provider details
NPI number
Gender
F
Contact information
Practice address
710 E 111TH PL, LOS ANGELES, CA 90059-1518
(323) 233-0425
(323) 232-2366
Mailing address
4211 AVALON BLVD, LOS ANGELES, CA 90011-5622
(323) 233-0425
(323) 232-2366
Taxonomy
Speciality
Code
Description
License number
State
1041C0700X
Clinical Social Worker
Primary
79411
CA
Other
Enumeration date
10/03/2012
Last updated
09/27/2017
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