Healthcare Provider Details

I. General information

NPI: 1700685526
Provider Name (Legal Business Name): WENDIE ELIZABETH WALLAERT
Entity Type: Individual
Gender:
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/12/2025
Last Update Date: 03/12/2025
Certification Date: 03/12/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2104 GREENBRIAR DR
SOUTHLAKE TX
76092-8355
US

IV. Provider business mailing address

2235 WASHINGTON AVE
FORT WORTH TX
76110-1960
US

V. Phone/Fax

Practice location:
  • Phone: 817-984-8655
  • Fax:
Mailing address:
  • Phone: 817-701-5203
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code106S00000X
TaxonomyBehavior Technician
License Number23-290366
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: