Provider Demographics
NPI:1811734882
Name:BRIGHT, WALLACE SAMUEL
Entity type:Individual
Prefix:MR
First Name:WALLACE
Middle Name:SAMUEL
Last Name:BRIGHT
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3750 SATELLITE BLVD
Mailing Address - Street 2:
Mailing Address - City:DULUTH
Mailing Address - State:GA
Mailing Address - Zip Code:30096-5056
Mailing Address - Country:US
Mailing Address - Phone:706-306-2450
Mailing Address - Fax:
Practice Address - Street 1:3750 SATELLITE BLVD
Practice Address - Street 2:
Practice Address - City:DULUTH
Practice Address - State:GA
Practice Address - Zip Code:30096-5056
Practice Address - Country:US
Practice Address - Phone:706-306-2450
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-07-09
Last Update Date:2024-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician