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General NPI Number Information
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NPI Number | 1689483182
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Entity Type | Individual
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Provider Name | DESEAN WALLACE
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Gender | Male
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Dates
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Enumeration Date | 12/31/2024
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Last Update Date | 01/13/2025
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Provider Practice Location Address
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Address Line | 6383 10TH AVE N STE E
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City | GREENACRES
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State | FL
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Zip | 33463-1689
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Country | US
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Telephone | 561-429-5794
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Fax |
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Provider Business Mailing Address
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Address Line | 5203 MATANZAS AVE
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City | FORT PIERCE
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State | FL
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Zip | 34946-1002
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Country | US
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Telephone | 706-832-5640
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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 | 103K00000X
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Taxonomy Name | Behavior Analyst
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License Number |
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License Number State |
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