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NPI Code Detail

MEDICARE: CAPRINXIA WALLACE

MEDICARE: CAPRINXIA 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
1106S00000XBehavior Technician

General Provider Information

NPI Number : 1477115434
Entity Type Code : Individual
Provider Name (Legal Business Name) : CAPRINXIA WALLACE
Provider Business Mailing Address
First Line : 300 INTERNATIONAL PKWY STE 200
Second Line :
City : LAKE MARY
State : FL
Zip : 32746-5028
Country : US
Telephone Number : 866-610-0580
Fax Number :
Provider Business Practice Location Address
First Line : 137 JOHNSON FERRY RD STE 2170
Second Line :
City : MARIETTA
State : GA
Zip : 30068-4948
Country : US
Telephone Number : 866-610-0580
Fax Number :
Authorized Official
Title or Position :
Name :
Credential :
Telephone Number :
Provider Enumeration Date : 06/30/2019
Last Update Date : 06/30/2019

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Directions to “ CAPRINXIA WALLACE ” Practice Location

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