Provider Demographics
NPI:1215388558
Name:EALY, DANITA WALLACE (MS, LPA, BCBA, LBA)
Entity Type:Individual
Prefix:
First Name:DANITA
Middle Name:WALLACE
Last Name:EALY
Suffix:
Gender:F
Credentials:MS, LPA, BCBA, LBA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2202 WELBORN DR
Mailing Address - Street 2:
Mailing Address - City:MISSOURI CITY
Mailing Address - State:TX
Mailing Address - Zip Code:77459-5162
Mailing Address - Country:US
Mailing Address - Phone:213-293-4393
Mailing Address - Fax:346-699-0169
Practice Address - Street 1:14090 SOUTHWEST FWY
Practice Address - Street 2:SUITE 300 #788
Practice Address - City:SUGAR LAND
Practice Address - State:TX
Practice Address - Zip Code:77478-2210
Practice Address - Country:US
Practice Address - Phone:213-293-4393
Practice Address - Fax:346-699-0169
Is Sole Proprietor?:Yes
Enumeration Date:2016-06-28
Last Update Date:2023-11-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX1-16-22409103K00000X
OK1-1622409103K00000X
TX37235103T00000X
TX1322103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst
No103T00000XBehavioral Health & Social Service ProvidersPsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX432112701Medicaid