Provider Demographics
NPI:1366204257
Name:WALLACE, ELIZABETH MARIE
Entity type:Individual
Prefix:
First Name:ELIZABETH
Middle Name:MARIE
Last Name:WALLACE
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:LIBBY
Other - Middle Name:
Other - Last Name:WALLACE
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:20015 NE LAKIN RD
Mailing Address - Street 2:
Mailing Address - City:BATTLE GROUND
Mailing Address - State:WA
Mailing Address - Zip Code:98604-9609
Mailing Address - Country:US
Mailing Address - Phone:360-896-3893
Mailing Address - Fax:
Practice Address - Street 1:20015 NE LAKIN RD
Practice Address - Street 2:
Practice Address - City:BATTLE GROUND
Practice Address - State:WA
Practice Address - Zip Code:98604-9609
Practice Address - Country:US
Practice Address - Phone:360-896-3893
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-01-25
Last Update Date:2024-01-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WA106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician