Provider Demographics
NPI:1538657051
Name:WALLACE, SADIE NOELLE
Entity Type:Individual
Prefix:
First Name:SADIE
Middle Name:NOELLE
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:PO BOX 1823
Mailing Address - Street 2:
Mailing Address - City:WEST MONROE
Mailing Address - State:LA
Mailing Address - Zip Code:71294-1823
Mailing Address - Country:US
Mailing Address - Phone:318-588-8908
Mailing Address - Fax:318-588-8909
Practice Address - Street 1:4440 VIKING DR STE 400
Practice Address - Street 2:
Practice Address - City:BOSSIER CITY
Practice Address - State:LA
Practice Address - Zip Code:71111-7511
Practice Address - Country:US
Practice Address - Phone:318-588-8908
Practice Address - Fax:318-588-8909
Is Sole Proprietor?:No
Enumeration Date:2018-04-30
Last Update Date:2021-03-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
106E00000X
LAL-494103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst
No106E00000XBehavioral Health & Social Service ProvidersAssistant Behavior Analyst
Provider Identifiers
StateIdentifier IDID TypeIssuer
LAL-494OtherSTATE LICENSE FOR BEHAVIOR ANALYST
1-20-43732OtherNATIONAL BOARD ANALYST BOARD CERTIFICATION