Provider Demographics
NPI:1629618855
Name:WAINRIGHT, TALLIA MELISSA
Entity Type:Individual
Prefix:
First Name:TALLIA
Middle Name:MELISSA
Last Name:WAINRIGHT
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:TALLIA
Other - Middle Name:MELISSA
Other - Last Name:SUCH
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:118 SALADO RIVER PL
Mailing Address - Street 2:
Mailing Address - City:CLINT
Mailing Address - State:TX
Mailing Address - Zip Code:79836-6734
Mailing Address - Country:US
Mailing Address - Phone:915-226-8344
Mailing Address - Fax:
Practice Address - Street 1:106 E 6TH ST
Practice Address - Street 2:
Practice Address - City:AUSTIN
Practice Address - State:TX
Practice Address - Zip Code:78701-3659
Practice Address - Country:US
Practice Address - Phone:855-832-6727
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-01-15
Last Update Date:2020-01-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXBACB543842106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician