MEDICARE: KINSEY MARIE WALLACE

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	103K00000X	Behavior Analyst

General Provider Information

NPI Number	:	1356273544
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	KINSEY MARIE WALLACE

Provider Business Mailing Address
First Line	:	1729 W GREENTREE DR STE 103
Second Line	:
City	:	TEMPE
State	:	AZ
Zip	:	85284-2712
Country	:	US
Telephone Number	:	801-362-5528
Fax Number	:

Provider Business Practice Location Address
First Line	:	1729 W GREENTREE DR STE 103
Second Line	:
City	:	TEMPE
State	:	AZ
Zip	:	85284-2712
Country	:	US
Telephone Number	:	602-892-4782
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	06/01/2026
Last Update Date	:	06/01/2026

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Directions to “ KINSEY MARIE WALLACE ” Practice Location

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