Individual
MR. DIVIER J WALLACE
Active
Sole proprietor
No
Provider details
NPI number
Gender
Man
Credential
M.A./MFTI
Contact information
Practice address
400 ESTUDILLO AVE STE 100, SAN LEANDRO, CA 94577-4962
(510) 924-0548
Mailing address
400 ESTUDILLO AVE STE 100, SAN LEANDRO, CA 94577-4962
(510) 924-0548
Taxonomy
Speciality
Code
Description
License number
State
101Y00000X
Counselor
Primary
—
—
106H00000X
Marriage & Family Therapist
61914
CA
171M00000X
Case Manager/Care Coordinator
—
—
Other
Enumeration date
05/16/2011
Last updated
06/17/2021
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