Provider Demographics
NPI:1477288561
Name:WALLACE, ADRIENNE (MA, BCBA)
Entity Type:Individual
Prefix:
First Name:ADRIENNE
Middle Name:
Last Name:WALLACE
Suffix:
Gender:F
Credentials:MA, BCBA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:810 W 53RD ST
Mailing Address - Street 2:
Mailing Address - City:ANDERSON
Mailing Address - State:IN
Mailing Address - Zip Code:46013-1516
Mailing Address - Country:US
Mailing Address - Phone:765-667-4967
Mailing Address - Fax:
Practice Address - Street 1:810 W 53RD ST
Practice Address - Street 2:
Practice Address - City:ANDERSON
Practice Address - State:IN
Practice Address - Zip Code:46013-1516
Practice Address - Country:US
Practice Address - Phone:765-667-4967
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-07-21
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst