MEDICARE: TAJA MARSHAE WALLACE RBT

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	23-267246	TX

General Provider Information

NPI Number	:	1326996380
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	TAJA MARSHAE WALLACE RBT

Provider Business Mailing Address
First Line	:	205 AGAVE BLOOM CV
Second Line	:
City	:	AUSTIN
State	:	TX
Zip	:	78738-1802
Country	:	US
Telephone Number	:	512-881-8782
Fax Number	:	512-885-2497

Provider Business Practice Location Address
First Line	:	950 FM 2001 APT 825
Second Line	:
City	:	BUDA
State	:	TX
Zip	:	78610-3959
Country	:	US
Telephone Number	:	254-420-8026
Fax Number	:

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

Provider Enumeration Date	:	03/17/2026
Last Update Date	:	03/17/2026

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