Individual
AUDREY LUCILLE WALLACE
Active
Sole proprietor
No
Provider details
NPI number
Gender
F
Contact information
Practice address
26034 CEMETERY RD, JERSEYVILLE, IL 62052-6385
(618) 535-2112
Mailing address
26034 CEMETERY RD, JERSEYVILLE, IL 62052-6385
Taxonomy
Speciality
Code
Description
License number
State
106S00000X
Behavior Technician
Primary
—
IL
Other
Enumeration date
09/09/2024
Last updated
09/09/2024
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