MEDICARE: SADIE NOELLE 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	106E00000X	Assistant Behavior Analyst
2	103K00000X	Behavior Analyst	L-494	LA

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	L-494	OTHER	LA	STATE LICENSE FOR BEHAVIOR ANALYST
2	1-20-43732	OTHER		NATIONAL BOARD ANALYST BOARD CERTIFICATION

General Provider Information

NPI Number	:	1538657051
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	SADIE NOELLE WALLACE

Provider Business Mailing Address
First Line	:	PO BOX 1823
Second Line	:
City	:	WEST MONROE
State	:	LA
Zip	:	71294-1823
Country	:	US
Telephone Number	:	318-588-8908
Fax Number	:	318-588-8909

Provider Business Practice Location Address
First Line	:	4440 VIKING DR STE 400
Second Line	:
City	:	BOSSIER CITY
State	:	LA
Zip	:	71111-7511
Country	:	US
Telephone Number	:	318-588-8908
Fax Number	:	318-588-8909

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

Provider Enumeration Date	:	04/30/2018
Last Update Date	:	03/29/2021

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Directions to “ SADIE NOELLE WALLACE ” Practice Location

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