Individual
DR. KATHLEEN M. WALLACE
Active
Sole proprietor
Yes
Provider details
NPI number
Gender
F
Credential
PSY.D
Contact information
Practice address
3400 WARREN-SHARON ROAD, VIENNA,, OH 44473-9532
(330) 720-5786
Mailing address
3438 WARREN SHARON RD, VIENNA, OH 44473-9532
(330) 720-5786
Taxonomy
Speciality
Code
Description
License number
State
103TC0700X
Clinical Psychologist
4820
OH
103TC0700X
Clinical Psychologist
Primary
PS015630
PA
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
000000867501
ANTHEM BLUE CROSS BLUE SHIELD
—
01
—
001947342
HIGHMARK BLUE SHIELD
PA
05
—
0213754
—
OH
05
—
102574943
—
PA
01
—
1044444
CIGNA
—
01
—
175402
MHNET
—
01
—
251830792
MULTIPLAN PHCS
—
01
—
7412444
AETNA
—
Enumeration date
01/19/2007
Last updated
09/15/2025
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