Provider Demographics
NPI:1346789443
Name:WALLACE, BOBBY (BA)
Entity Type:Individual
Prefix:
First Name:BOBBY
Middle Name:
Last Name:WALLACE
Suffix:
Gender:M
Credentials:BA
Other - Prefix:
Other - First Name:BOBBY
Other - Middle Name:
Other - Last Name:WALLACE
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:BA
Mailing Address - Street 1:3221 BEHRMAN PL
Mailing Address - Street 2:
Mailing Address - City:NEW ORLEANS
Mailing Address - State:LA
Mailing Address - Zip Code:70114-8200
Mailing Address - Country:US
Mailing Address - Phone:504-263-2800
Mailing Address - Fax:
Practice Address - Street 1:3221 BEHRMAN PL
Practice Address - Street 2:
Practice Address - City:NEW ORLEANS
Practice Address - State:LA
Practice Address - Zip Code:70114-8200
Practice Address - Country:US
Practice Address - Phone:504-263-2800
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-02-22
Last Update Date:2017-02-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA1346524378Medicaid