Healthcare Provider Details

I. General information

NPI: 1801705199
Provider Name (Legal Business Name): ERIN WALLACE
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/03/2026
Last Update Date: 09/03/2026
Certification Date: 09/01/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

10801 BLACK BEAR ROAD
JUNEAU AK
99081
US

IV. Provider business mailing address

PO BOX 32829
JUNEAU AK
99803
US

V. Phone/Fax

Practice location:
  • Phone: 907-723-9436
  • Fax:
Mailing address:
  • Phone: 907-723-9436
  • Fax: 907-789-8443

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code106S00000X
TaxonomyBehavior Technician
License Number
License Number StateAK

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: