Provider Demographics
NPI:1497319529
Name:WALLACE, ZAKARY RUSSELL (MS, BCBA, LBA)
Entity Type:Individual
Prefix:
First Name:ZAKARY
Middle Name:RUSSELL
Last Name:WALLACE
Suffix:
Gender:M
Credentials:MS, BCBA, LBA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3500 DEPAUW BLVD STE 3070
Mailing Address - Street 2:
Mailing Address - City:INDIANAPOLIS
Mailing Address - State:IN
Mailing Address - Zip Code:46268-6135
Mailing Address - Country:US
Mailing Address - Phone:855-324-0885
Mailing Address - Fax:317-520-8200
Practice Address - Street 1:2427 RUSSELLVILLE RD
Practice Address - Street 2:
Practice Address - City:BOWLING GREEN
Practice Address - State:KY
Practice Address - Zip Code:42101-3980
Practice Address - Country:US
Practice Address - Phone:270-936-7472
Practice Address - Fax:317-520-8200
Is Sole Proprietor?:No
Enumeration Date:2019-04-24
Last Update Date:2021-11-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
103K00000X
RBT-19-84856106S00000X
KY274223103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst
No106S00000XBehavioral Health & Social Service ProvidersBehavior Technician
Provider Identifiers
StateIdentifier IDID TypeIssuer
1-21-53785OtherBCBA CERTIFICATE
RBT-19-84856OtherRBT