Provider Demographics
NPI:1053122168
Name:WALLACE, BRIANNA R
Entity type:Individual
Prefix:
First Name:BRIANNA
Middle Name:R
Last Name:WALLACE
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2230 OAKBRIDGE WAY
Mailing Address - Street 2:
Mailing Address - City:ORLANDO
Mailing Address - State:FL
Mailing Address - Zip Code:32808-4427
Mailing Address - Country:US
Mailing Address - Phone:407-761-9837
Mailing Address - Fax:
Practice Address - Street 1:2930 MAGUIRE RD
Practice Address - Street 2:
Practice Address - City:OCOEE
Practice Address - State:FL
Practice Address - Zip Code:34761-4750
Practice Address - Country:US
Practice Address - Phone:407-602-5010
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2025-01-17
Last Update Date:2025-01-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician