Healthcare Provider Details

I. General information

NPI: 1689244972
Provider Name (Legal Business Name): ELIZABETH WALLACE
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/29/2021
Last Update Date: 11/15/2022
Certification Date: 11/15/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3500 7TH AVE S
BIRMINGHAM AL
35222-3211
US

IV. Provider business mailing address

5360 PARK SIDE CIR
HOOVER AL
35244-5142
US

V. Phone/Fax

Practice location:
  • Phone: 205-963-7682
  • Fax: 317-520-8200
Mailing address:
  • Phone: 225-620-8432
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103K00000X
TaxonomyBehavior Analyst
License Number
License Number StateNULL
# 2
Primary TaxonomyN
Taxonomy Code106S00000X
TaxonomyBehavior Technician
License Number
License Number StateNULL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: