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General NPI Number Information
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NPI Number | 1073499802
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Entity Type | Individual
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Provider Name | TALESA WALLACE
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Gender | Female
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Dates
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Enumeration Date | 08/15/2025
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Last Update Date | 08/15/2025
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Provider Practice Location Address
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Address Line | 3832 SW 33RD CT
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City | WEST PARK
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State | FL
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Zip | 33023-5631
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Country | US
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Telephone | 954-947-5061
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Fax |
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Provider Business Mailing Address
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Address Line | 1250 POWDER SPRINGS ST APT 101
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City | MARIETTA
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State | GA
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Zip | 30064-5202
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Country | US
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Telephone | 404-509-0023
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 106S00000X
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Taxonomy Name | Behavior Technician
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License Number | RBT-24-391137
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License Number State | GA
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