| NPI | 1083259063 |
|---|---|
| Former Name | TATIYANA RENAE ROSE WALLACE |
| Entity Type | Individual |
| Gender | Female |
| Sole Proprietor ? | No |
| Primary Taxonomy | 101YM0800X Counselor, Mental Health (Licence: WA CG61022955) |
| Additional Taxonomies | 101YM0800X Counselor, Mental Health |
| Enumeration Date | 2019-11-13 |
| Last Update Date | 2020-01-27 |