Provider Demographics
NPI:1780300384
Name:WALLACE, PRECIOUS ZORIA RENEE
Entity type:Individual
Prefix:MRS
First Name:PRECIOUS
Middle Name:ZORIA RENEE
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 1:8801 NW 78TH PL APT 407
Mailing Address - Street 2:
Mailing Address - City:TAMARAC
Mailing Address - State:FL
Mailing Address - Zip Code:33321-1468
Mailing Address - Country:US
Mailing Address - Phone:954-422-7718
Mailing Address - Fax:
Practice Address - Street 1:8801 NW 78TH PL APT 407
Practice Address - Street 2:
Practice Address - City:TAMARAC
Practice Address - State:FL
Practice Address - Zip Code:33321-1468
Practice Address - Country:US
Practice Address - Phone:954-422-7718
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-10-14
Last Update Date:2022-10-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician