Individual
MADISON WALLACE
Active
Sole proprietor
No
Provider details
NPI number
Gender
F
Contact information
Practice address
1025 SE 11TH AVE APT 302, PORTLAND, OR 97214-2482
(503) 686-1786
Mailing address
1025 SE 11TH AVE APT 302, PORTLAND, OR 97214-2482
Taxonomy
Speciality
Code
Description
License number
State
106S00000X
Behavior Technician
Primary
—
—
Other
Enumeration date
08/13/2019
Last updated
08/13/2019
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