Provider Demographics
NPI:1588397640
Name:WALLACE, BRUCE STERLING II (PSYD)
Entity type:Individual
Prefix:DR
First Name:BRUCE
Middle Name:STERLING
Last Name:WALLACE
Suffix:II
Gender:M
Credentials:PSYD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3631 E 1ST ST APT 2
Mailing Address - Street 2:
Mailing Address - City:LONG BEACH
Mailing Address - State:CA
Mailing Address - Zip Code:90803-2793
Mailing Address - Country:US
Mailing Address - Phone:323-770-3058
Mailing Address - Fax:
Practice Address - Street 1:3631 E 1ST ST APT 2
Practice Address - Street 2:
Practice Address - City:LONG BEACH
Practice Address - State:CA
Practice Address - Zip Code:90803-2793
Practice Address - Country:US
Practice Address - Phone:323-770-3058
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-07-06
Last Update Date:2022-07-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPSY31610103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical