Provider Demographics
NPI:1619548336
Name:WALLACE, KRISTEN
Entity Type:Individual
Prefix:
First Name:KRISTEN
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 1:2810 COLISEUM CENTRE DR STE 520
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28217-3252
Mailing Address - Country:US
Mailing Address - Phone:980-785-1113
Mailing Address - Fax:980-785-1114
Practice Address - Street 1:834 TYVOLA RD STE 126
Practice Address - Street 2:
Practice Address - City:CHARLOTTE
Practice Address - State:NC
Practice Address - Zip Code:28217-3598
Practice Address - Country:US
Practice Address - Phone:980-785-1113
Practice Address - Fax:980-785-1114
Is Sole Proprietor?:No
Enumeration Date:2021-07-03
Last Update Date:2022-08-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC1-21-51057103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst