Provider Demographics
NPI:1477894251
Name:WALLACE, DORE ANDREW (BCBA)
Entity Type:Individual
Prefix:MR
First Name:DORE
Middle Name:ANDREW
Last Name:WALLACE
Suffix:
Gender:M
Credentials:BCBA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:15720 VENTURA BLVD
Mailing Address - Street 2:SUITE 403
Mailing Address - City:ENCINO
Mailing Address - State:CA
Mailing Address - Zip Code:91436-2914
Mailing Address - Country:US
Mailing Address - Phone:818-788-2388
Mailing Address - Fax:
Practice Address - Street 1:15720 VENTURA BLVD
Practice Address - Street 2:SUITE 403
Practice Address - City:ENCINO
Practice Address - State:CA
Practice Address - Zip Code:91436-2914
Practice Address - Country:US
Practice Address - Phone:818-788-2388
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-03-04
Last Update Date:2013-03-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA1-12-12251103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst