Provider Demographics
NPI:1093355455
Name:WALLACE, KRISTI (RBT)
Entity Type:Individual
Prefix:
First Name:KRISTI
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 1:14131 MIDWAY RD STE 800
Mailing Address - Street 2:
Mailing Address - City:ADDISON
Mailing Address - State:TX
Mailing Address - Zip Code:75001-3627
Mailing Address - Country:US
Mailing Address - Phone:469-351-4203
Mailing Address - Fax:469-914-7875
Practice Address - Street 1:6102 82ND ST STE 10
Practice Address - Street 2:
Practice Address - City:LUBBOCK
Practice Address - State:TX
Practice Address - Zip Code:79424-0802
Practice Address - Country:US
Practice Address - Phone:806-993-3333
Practice Address - Fax:806-319-8840
Is Sole Proprietor?:No
Enumeration Date:2020-01-13
Last Update Date:2022-02-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXRBT-20-110103106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician
Provider Identifiers
StateIdentifier IDID TypeIssuer
TXRBT-20-110103OtherBACB