Provider Demographics
NPI:1194300657
Name:WALLACE, KATHRYN ABBIE (MA, BCBA, LABA)
Entity type:Individual
Prefix:
First Name:KATHRYN
Middle Name:ABBIE
Last Name:WALLACE
Suffix:
Gender:F
Credentials:MA, BCBA, LABA
Other - Prefix:
Other - First Name:KATHRYN
Other - Middle Name:ABBIE
Other - Last Name:ATKINS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MA, BCBA, LABA
Mailing Address - Street 1:33 PERRY AVE
Mailing Address - Street 2:
Mailing Address - City:ATTLEBORO
Mailing Address - State:MA
Mailing Address - Zip Code:02703-2417
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:33 PERRY AVE
Practice Address - Street 2:
Practice Address - City:ATTLEBORO
Practice Address - State:MA
Practice Address - Zip Code:02703-2417
Practice Address - Country:US
Practice Address - Phone:571-201-5237
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-03-16
Last Update Date:2022-01-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA3448103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst