Provider Demographics
NPI:1053111534
Name:WALLACE, BRITTNEY
Entity type:Individual
Prefix:
First Name:BRITTNEY
Middle Name:
Last Name:WALLACE
Suffix:
Gender:
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1301 JUDSON ST
Mailing Address - Street 2:
Mailing Address - City:EVANSVILLE
Mailing Address - State:IN
Mailing Address - Zip Code:47713-1454
Mailing Address - Country:US
Mailing Address - Phone:812-435-8304
Mailing Address - Fax:
Practice Address - Street 1:1301 JUDSON ST
Practice Address - Street 2:
Practice Address - City:EVANSVILLE
Practice Address - State:IN
Practice Address - Zip Code:47713-1454
Practice Address - Country:US
Practice Address - Phone:812-435-8304
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2025-03-14
Last Update Date:2025-03-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN10072706103TS0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TS0200XBehavioral Health & Social Service ProvidersPsychologistSchool