Provider Demographics
NPI:1124705587
Name:WALLACE ANDREWS LLC
Entity type:Organization
Organization Name:WALLACE ANDREWS LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:BHT/FACILITATOR/WELLNESS COACH
Authorized Official - Prefix:MR
Authorized Official - First Name:WALLACE
Authorized Official - Middle Name:CLYDE
Authorized Official - Last Name:ANDREWS
Authorized Official - Suffix:III
Authorized Official - Credentials:BEHAVIORAL HEALTH
Authorized Official - Phone:480-925-1393
Mailing Address - Street 1:1453 N DYSART RD STE 322
Mailing Address - Street 2:
Mailing Address - City:AVONDALE
Mailing Address - State:AZ
Mailing Address - Zip Code:85323-1539
Mailing Address - Country:US
Mailing Address - Phone:480-925-1393
Mailing Address - Fax:
Practice Address - Street 1:1121 W BELL RD STE 373
Practice Address - Street 2:
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85023-3516
Practice Address - Country:US
Practice Address - Phone:480-925-1393
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2023-06-28
Last Update Date:2023-06-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior TechnicianGroup - Multi-Specialty
No102X00000XBehavioral Health & Social Service ProvidersPoetry TherapistGroup - Multi-Specialty
No171400000XOther Service ProvidersHealth & Wellness CoachGroup - Multi-Specialty
No225800000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersRecreation TherapistGroup - Multi-Specialty
No253Z00000XAgenciesIn Home Supportive CareGroup - Multi-Specialty
No282J00000XHospitalsReligious Nonmedical Health Care Institution