Provider Demographics
NPI:1477276350
Name:WALLACE, HALEY
Entity Type:Individual
Prefix:
First Name:HALEY
Middle Name:
Last Name:WALLACE
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1751 ASHLAND CITY RD APT K81
Mailing Address - Street 2:
Mailing Address - City:CLARKSVILLE
Mailing Address - State:TN
Mailing Address - Zip Code:37043-4861
Mailing Address - Country:US
Mailing Address - Phone:931-494-7870
Mailing Address - Fax:
Practice Address - Street 1:401 S MOUNT JULIET RD STE 235-118
Practice Address - Street 2:
Practice Address - City:MT JULIET
Practice Address - State:TN
Practice Address - Zip Code:37122-6359
Practice Address - Country:US
Practice Address - Phone:703-506-0123
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-09-26
Last Update Date:2022-09-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician