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NPI Code Detail

MEDICARE: TAKIA WALLACE

MEDICARE: TAKIA 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 TechnicianRBT-21-195151GA

General Provider Information

NPI Number : 1780342089
Entity Type Code : Individual
Provider Name (Legal Business Name) : TAKIA WALLACE
Provider Business Mailing Address
First Line : 3736 EXECUTIVE CENTER DR
Second Line :
City : AUGUSTA
State : GA
Zip : 30907-2360
Country : US
Telephone Number : 706-842-5330
Fax Number : 706-842-5340
Provider Business Practice Location Address
First Line : 101 ROSSMORE PL
Second Line :
City : AUGUSTA
State : GA
Zip : 30909-5771
Country : US
Telephone Number : 706-842-5330
Fax Number : 706-842-5340
Authorized Official
Title or Position :
Name :
Credential :
Telephone Number :
Provider Enumeration Date : 12/03/2021
Last Update Date : 12/03/2021

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Directions to “ TAKIA WALLACE ” Practice Location

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