MEDICARE: ALLYSHIA WALLACE

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	106S00000X	Behavior Technician

General Provider Information

NPI Number	:	1265195804
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	ALLYSHIA WALLACE

Provider Business Mailing Address
First Line	:	14864 COUNTY ROAD 433
Second Line	:
City	:	TYLER
State	:	TX
Zip	:	75706-3206
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	14623 FM 849
Second Line	:
City	:	LINDALE
State	:	TX
Zip	:	75771-2440
Country	:	US
Telephone Number	:	430-235-2089
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	10/20/2021
Last Update Date	:	10/20/2021

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Directions to “ ALLYSHIA WALLACE ” Practice Location

Language	Start Address	Practice Location

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