Provider Demographics
NPI:1285940668
Name:WALLACE, FABIOLA ELIZABETH
Entity type:Individual
Prefix:
First Name:FABIOLA
Middle Name:ELIZABETH
Last Name:WALLACE
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:FABIOLA
Other - Middle Name:ELIZABETH
Other - Last Name:RUIZ
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:520 E TULARE AVE
Mailing Address - Street 2:
Mailing Address - City:VISALIA
Mailing Address - State:CA
Mailing Address - Zip Code:93292-3629
Mailing Address - Country:US
Mailing Address - Phone:559-623-0909
Mailing Address - Fax:
Practice Address - Street 1:520 E TULARE AVE
Practice Address - Street 2:
Practice Address - City:VISALIA
Practice Address - State:CA
Practice Address - Zip Code:93292
Practice Address - Country:US
Practice Address - Phone:559-623-0969
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-08-24
Last Update Date:2018-09-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA90196106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist