Individual
ANTOINE WALLACE
Active
Sole proprietor
No
Provider details
NPI number
Gender
Man
Contact information
Practice address
6355 WOODSIDE CT, COLUMBIA, MD 21046-1071
(410) 381-7171
Mailing address
6355 WOODSIDE CT, COLUMBIA, MD 21046-1071
Taxonomy
Speciality
Code
Description
License number
State
106S00000X
Behavior Technician
Primary
—
—
Other
Enumeration date
10/20/2017
Last updated
10/20/2017
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