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General NPI Number Information
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NPI Number | 1184529570
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Entity Type | Individual
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Provider Name | LILLIAN ROSE WALLACE
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Gender | Female
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Dates
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Enumeration Date | 10/14/2026
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Last Update Date | 10/14/2026
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Provider Practice Location Address
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Address Line | 647 13TH AVE E
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City | WEST FARGO
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State | ND
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Zip | 58078-3328
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Country | US
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Telephone | 701-277-8844
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Fax |
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Provider Business Mailing Address
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Address Line | 1815 UNIVERSITY DR N NORTH PO #287 (EMMETT AND DONOVAN)
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City | FARGO
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State | ND
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Zip | 58102
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Country | US
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Telephone | 763-772-7764
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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 |
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License Number State | ND
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