Individual
STEPHEN WALLACE
Active
Sole proprietor
No
Provider details
NPI number
Gender
Man
Credential
RBT
Contact information
Practice address
403 N 4TH ST, LEAVENWORTH, KS 66048-1966
(913) 250-5509
Mailing address
403 N 4TH ST, LEAVENWORTH, KS 66048-1966
Taxonomy
Speciality
Code
Description
License number
State
106S00000X
Behavior Technician
Primary
RBT-20-130807
MO
Other
Enumeration date
08/06/2020
Last updated
08/17/2020
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