Healthcare Provider Details

I. General information

NPI: 1073499802
Provider Name (Legal Business Name): TALESA WALLACE
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/15/2025
Last Update Date: 08/15/2025
Certification Date: 08/15/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3832 SW 33RD CT
WEST PARK FL
33023-5631
US

IV. Provider business mailing address

1250 POWDER SPRINGS ST APT 101
MARIETTA GA
30064-5202
US

V. Phone/Fax

Practice location:
  • Phone: 954-947-5061
  • Fax:
Mailing address:
  • Phone: 404-509-0023
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code106S00000X
TaxonomyBehavior Technician
License NumberRBT-24-391137
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: