Ian Joseph Wallace, PH.D.

Primary specialty

PsychologistTaxonomy code 103T00000X

License

PSY# 23646 Issued in CA

Practice address

200 Maritime Academy Dr
The California Maritime Academy, Student Health Service
Vallejo, CA 94590-8181

Phone

(707) 654-1170

Fax

(707) 654-1171

NPI assigned

Jun 2, 2009

Sex

Male

Sole proprietor

No

Registry information is reported by the provider to CMS and is not verified. About this source

Specialties & licenses 1

Addresses

Medicare fee-for-service enrollment

Not listed in the public Medicare enrollment file

Medicare enrollment (NPD)

Not enrolled

Credentials

Doctor of Philosophy

State licenses

Practice roles

Organizations this provider is connected to: Medicare benefit reassignments (the organization bills Medicare for this provider’s services), Care Compare group memberships and National Provider Directory roles.

• California Maritime Academy

  • Student Health Clinic/Center
  • Vallejo, CA
  • NPI 1073813341
  NPD (past)

The complete NPPES record for this NPI in the NPI Registry API format.

{
    "created_epoch": "1243900800000",
    "enumeration_type": "NPI-1",
    "last_updated_epoch": "1374537600000",
    "number": "1013143262",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "200 MARITIME ACADEMY DR",
            "address_2": "THE CALIFORNIA MARITIME ACADEMY, STUDENT HEALTH SERVICE",
            "city": "VALLEJO",
            "state": "CA",
            "postal_code": "945908181",
            "telephone_number": "707-654-1170",
            "fax_number": "707-654-1171"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "200 MARITIME ACADEMY DR",
            "address_2": "THE CALIFORNIA MARITIME ACADEMY, STUDENT HEALTH SERVICE",
            "city": "VALLEJO",
            "state": "CA",
            "postal_code": "945908181",
            "telephone_number": "707-654-1170",
            "fax_number": "707-654-1171"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "last_name": "WALLACE",
        "first_name": "IAN",
        "middle_name": "JOSEPH",
        "name_prefix": "Dr.",
        "credential": "PH.D.",
        "sole_proprietor": "NO",
        "sex": "M",
        "enumeration_date": "2009-06-02",
        "last_updated": "2013-07-23",
        "status": "A"
    },
    "taxonomies": [
        {
            "code": "103T00000X",
            "taxonomy_group": "",
            "desc": "Psychologist",
            "state": "CA",
            "license": "PSY# 23646",
            "primary": true
        }
    ],
    "identifiers": [],
    "endpoints": [],
    "other_names": []
}

• Carrielee Nicole Walker
• Charles A Walker, PHARM D
• Jacquae M. Walker, MD
• Jean Westley Wall, C.P.N.P.
• Christopher Wade Wallace, M.D.
• Jamie P Wallace, SUD COUNSELOR
• Walmart Inc.
• Tanisha Nicole Walters
• Brynn Walund
• Charisse Wan, SLP CA LICENSE 4032

• Psychologist in Vallejo, CA
• Providers in Vallejo, CA by specialty
• Psychologist in California

• NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Jul 23, 2013; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
• National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.

Verify at the official NPI Registry.