Provider Demographics
NPI:1902958119
Name:WALLIS, TRISHA DIANNE (MSW, LCSW, PSYD)
Entity Type:Individual
Prefix:DR
First Name:TRISHA
Middle Name:DIANNE
Last Name:WALLIS
Suffix:
Gender:F
Credentials:MSW, LCSW, PSYD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 160322
Mailing Address - Street 2:
Mailing Address - City:SACRAMENTO
Mailing Address - State:CA
Mailing Address - Zip Code:95816-0322
Mailing Address - Country:US
Mailing Address - Phone:916-996-5424
Mailing Address - Fax:
Practice Address - Street 1:425 UNIVERSITY AVE STE 100
Practice Address - Street 2:
Practice Address - City:SACRAMENTO
Practice Address - State:CA
Practice Address - Zip Code:95825-6508
Practice Address - Country:US
Practice Address - Phone:916-996-5424
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-01-17
Last Update Date:2020-05-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA268621041C0700X
CA29917103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
No1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical