Provider Demographics
NPI:1225431190
Name:WALLACE, THEODORE JR
Entity Type:Individual
Prefix:
First Name:THEODORE
Middle Name:
Last Name:WALLACE
Suffix:JR
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:66 ROCKHAVEN COURT
Mailing Address - Street 2:
Mailing Address - City:READING
Mailing Address - State:PA
Mailing Address - Zip Code:19606
Mailing Address - Country:US
Mailing Address - Phone:215-399-8996
Mailing Address - Fax:
Practice Address - Street 1:66 ROCKHAVEN COURT
Practice Address - Street 2:
Practice Address - City:READING
Practice Address - State:PA
Practice Address - Zip Code:19606
Practice Address - Country:US
Practice Address - Phone:215-399-8996
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-10-06
Last Update Date:2014-10-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PABH0001046103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst