Provider Demographics
NPI:1073264289
Name:WALLACE, YIDEIRA (RBT)
Entity Type:Individual
Prefix:MRS
First Name:YIDEIRA
Middle Name:
Last Name:WALLACE
Suffix:
Gender:F
Credentials:RBT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4584 FLINT DR
Mailing Address - Street 2:
Mailing Address - City:NORTH PORT
Mailing Address - State:FL
Mailing Address - Zip Code:34286-6604
Mailing Address - Country:US
Mailing Address - Phone:786-570-3643
Mailing Address - Fax:
Practice Address - Street 1:4584 FLINT DR
Practice Address - Street 2:
Practice Address - City:NORTH PORT
Practice Address - State:FL
Practice Address - Zip Code:34286-6604
Practice Address - Country:US
Practice Address - Phone:786-570-3643
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-01-10
Last Update Date:2022-01-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLRBT-21-195063106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician