Provider Demographics
NPI:1407355019
Name:WALLACE, SHAWNESHA (BCBA, LBA)
Entity Type:Individual
Prefix:MRS
First Name:SHAWNESHA
Middle Name:
Last Name:WALLACE
Suffix:
Gender:F
Credentials:BCBA, LBA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10214 E CALLE ESTRELLA POLAR
Mailing Address - Street 2:
Mailing Address - City:TUCSON
Mailing Address - State:AZ
Mailing Address - Zip Code:85747-5169
Mailing Address - Country:US
Mailing Address - Phone:520-230-6965
Mailing Address - Fax:
Practice Address - Street 1:1200 N EL DORADO PL STE G700
Practice Address - Street 2:
Practice Address - City:TUCSON
Practice Address - State:AZ
Practice Address - Zip Code:85715-4637
Practice Address - Country:US
Practice Address - Phone:520-526-0050
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-02-09
Last Update Date:2018-12-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZBEH-000379103K00000X
106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst