Provider Demographics
NPI:1548523814
Name:WALLACE, TIARA B
Entity type:Individual
Prefix:
First Name:TIARA
Middle Name:B
Last Name:WALLACE
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9255 N MACARTHUR BLVD APT B
Mailing Address - Street 2:
Mailing Address - City:OKLAHOMA CITY
Mailing Address - State:OK
Mailing Address - Zip Code:73132-2435
Mailing Address - Country:US
Mailing Address - Phone:405-974-0115
Mailing Address - Fax:
Practice Address - Street 1:9255 N MACARTHUR BLVD APT B
Practice Address - Street 2:
Practice Address - City:OKLAHOMA CITY
Practice Address - State:OK
Practice Address - Zip Code:73132-2435
Practice Address - Country:US
Practice Address - Phone:405-974-0115
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-06-20
Last Update Date:2012-06-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst