1457616575 NPI number — MRS. CARRIE EILEEN WALLS-SUAREZ BCBA

Table of content: MRS. CARRIE EILEEN WALLS-SUAREZ BCBA (NPI 1457616575)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1457616575 NPI number — MRS. CARRIE EILEEN WALLS-SUAREZ BCBA

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
WALLS-SUAREZ
Provider First Name:
CARRIE
Provider Middle Name:
EILEEN
Provider Name Prefix Text:
MRS.
Provider Name Suffix Text:
Provider Credential Text:
BCBA
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
WALLS
Provider Other First Name:
CARRIE
Provider Other Middle Name:
EILEEN
Provider Other Name Prefix Text:
MISS
Provider Other Name Suffix Text:
Provider Other Credential Text:
BCBA
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1457616575
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
01/28/2021
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
5818 WILMINGTON PIKE # 114
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
CENTERVILLE
Provider Business Mailing Address State Name:
OH
Provider Business Mailing Address Postal Code:
45459-7004
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
937-308-7047
Provider Business Mailing Address Fax Number:
937-343-6666

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
5265 SECRETARIAT DR
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
MORROW
Provider Business Practice Location Address State Name:
OH
Provider Business Practice Location Address Postal Code:
45152-5036
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
937-308-7047
Provider Business Practice Location Address Fax Number:
937-343-6666
Provider Enumeration Date:
07/05/2012

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 103K00000X , with the licence number:  1-12-11707 ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 224 . This is a "CERTIFIED OHIO BEHAVIOR ANALYST (COBA) NUMBER" identifier , issued by the state of ( OH ) . This identifiers is of the category "OTHER".




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