Provider Demographics
NPI:1053595264
Name:WALLANDER, ROBERT JOHN JR (BCBA-D)
Entity type:Individual
Prefix:DR
First Name:ROBERT
Middle Name:JOHN
Last Name:WALLANDER
Suffix:JR
Gender:M
Credentials:BCBA-D
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8706 BLOSSOM LN
Mailing Address - Street 2:
Mailing Address - City:LOUISVILLE
Mailing Address - State:KY
Mailing Address - Zip Code:40242-3104
Mailing Address - Country:US
Mailing Address - Phone:502-565-8189
Mailing Address - Fax:
Practice Address - Street 1:8706 BLOSSOM LN
Practice Address - Street 2:
Practice Address - City:LOUISVILLE
Practice Address - State:KY
Practice Address - Zip Code:40242-3104
Practice Address - Country:US
Practice Address - Phone:502-565-8189
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-12-24
Last Update Date:2015-06-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
1-01-0535103K00000X
KYKY-0041103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst