1770951394 NPI number — ASHLEY KATHLEEN WALLACE M.S., BCBA, LABA

Table of content: ASHLEY KATHLEEN WALLACE M.S., BCBA, LABA (NPI 1770951394)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1770951394 NPI number — ASHLEY KATHLEEN WALLACE M.S., BCBA, LABA

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
WALLACE
Provider First Name:
ASHLEY
Provider Middle Name:
KATHLEEN
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
M.S., BCBA, LABA
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1770951394
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
04/04/2017
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
11 HURON DR
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
NATICK
Provider Business Mailing Address State Name:
MA
Provider Business Mailing Address Postal Code:
01760-1336
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
508-651-7500
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
11 HURON DR
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
NATICK
Provider Business Practice Location Address State Name:
MA
Provider Business Practice Location Address Postal Code:
01760-1336
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
508-651-7500
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
09/14/2015

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:  1-13-14833 , registered in the state of VA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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





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