Provider Demographics
NPI:1770951394
Name:WALLACE, ASHLEY KATHLEEN (MS, BCBA, LABA)
Entity type:Individual
Prefix:
First Name:ASHLEY
Middle Name:KATHLEEN
Last Name:WALLACE
Suffix:
Gender:F
Credentials:MS, BCBA, LABA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11 HURON DR
Mailing Address - Street 2:
Mailing Address - City:NATICK
Mailing Address - State:MA
Mailing Address - Zip Code:01760-1336
Mailing Address - Country:US
Mailing Address - Phone:508-651-7500
Mailing Address - Fax:
Practice Address - Street 1:11 HURON DR
Practice Address - Street 2:
Practice Address - City:NATICK
Practice Address - State:MA
Practice Address - Zip Code:01760-1336
Practice Address - Country:US
Practice Address - Phone:508-651-7500
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-09-14
Last Update Date:2017-04-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA1-13-14833103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst