Susan O'Brien Wallace, PSY. D.

Primary specialty

Clinical PsychologistTaxonomy code 103TC0700X

License

PSY27744 Issued in CA

Practice address

1454 E 2ND St
San Bernardino, CA 92408-0118

Phone

(909) 382-7100

NPI assigned

Mar 28, 2008

Sex

Female

Sole proprietor

No

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

Specialties & licenses 2

Addresses

Medicare fee-for-service enrollment

Not listed in the public Medicare enrollment file

Medicare enrollment (NPD)

Enrolled

State licenses

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

{
    "created_epoch": "1206662400000",
    "enumeration_type": "NPI-1",
    "last_updated_epoch": "1519171200000",
    "number": "1295907392",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "530 S LAKE AVE # 565",
            "city": "PASADENA",
            "state": "CA",
            "postal_code": "911013515",
            "telephone_number": "619-665-7781"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "1454 E 2ND ST",
            "city": "SAN BERNARDINO",
            "state": "CA",
            "postal_code": "924080118",
            "telephone_number": "909-382-7100"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "last_name": "WALLACE",
        "first_name": "SUSAN",
        "middle_name": "O'BRIEN",
        "name_prefix": "Mrs.",
        "credential": "PSY. D.",
        "sole_proprietor": "NO",
        "sex": "F",
        "enumeration_date": "2008-03-28",
        "last_updated": "2018-02-21",
        "status": "A"
    },
    "taxonomies": [
        {
            "code": "101YM0800X",
            "taxonomy_group": "",
            "desc": "Counselor, Mental Health",
            "state": null,
            "license": null,
            "primary": false
        },
        {
            "code": "103TC0700X",
            "taxonomy_group": "",
            "desc": "Psychologist, Clinical",
            "state": "CA",
            "license": "PSY27744",
            "primary": true
        }
    ],
    "identifiers": [],
    "endpoints": [],
    "other_names": []
}

• Lavon Walker
• Leonie Walker, LCSW
• Patience Walker
• Daniel Montes Wallace
• Serena A Wallace, DPT
• Christa Ann Wallis, LMFT
• Antonia Walls
• Mysheva Walls
• Walmart Inc.
• Walmart Pharmacy

• Clinical Psychologist in San Bernardino, CA
• Providers in San Bernardino, CA by specialty
• Clinical Psychologist in California

• NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Feb 21, 2018; 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.