1770636367 NPI number — DR. KATHLEEN M. WALLACE PSY.D

Table of content: MRS. TALAT RAD CRNA (NPI 1528121241)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1770636367 NPI number — DR. KATHLEEN M. WALLACE PSY.D

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
WALLACE
Provider First Name:
KATHLEEN
Provider Middle Name:
M.
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
PSY.D
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1770636367
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
09/15/2025
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
3438 WARREN SHARON RD
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
VIENNA
Provider Business Mailing Address State Name:
OH
Provider Business Mailing Address Postal Code:
44473-9532
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
330-720-5786
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
3400 WARREN-SHARON ROAD
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
VIENNA
Provider Business Practice Location Address State Name:
OH
Provider Business Practice Location Address Postal Code:
44473-9532
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
330-720-5786
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
01/19/2007

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 103TC0700X , with the licence number:  PS015630 , registered in the state of PA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 103TC0700X , with the licence number: 4820 , registered in the state of OH ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 7412444 . This is a "AETNA" identifier . This identifiers is of the category "OTHER".
  • Identifier: 000000867501 . This is a "ANTHEM BLUE CROSS BLUE SHIELD" identifier . This identifiers is of the category "OTHER".
  • Identifier: 0213754 , issued by the state of ( OH ) . This identifiers is of the category "MEDICAID".
  • Identifier: 102574943 , issued by the state of ( PA ) . This identifiers is of the category "MEDICAID".
  • Identifier: 175402 . This is a "MHNET" identifier . This identifiers is of the category "OTHER".
  • Identifier: 001947342 . This is a "HIGHMARK BLUE SHIELD" identifier , issued by the state of ( PA ) . This identifiers is of the category "OTHER".
  • Identifier: 1044444 . This is a "CIGNA" identifier . This identifiers is of the category "OTHER".
  • Identifier: 251830792 . This is a "MULTIPLAN PHCS" identifier . This identifiers is of the category "OTHER".




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