Provider Demographics
NPI:1073499802
Name:WALLACE, TALESA
Entity type:Individual
Prefix:
First Name:TALESA
Middle Name:
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 1:1250 POWDER SPRINGS ST APT 101
Mailing Address - Street 2:
Mailing Address - City:MARIETTA
Mailing Address - State:GA
Mailing Address - Zip Code:30064-5202
Mailing Address - Country:US
Mailing Address - Phone:404-509-0023
Mailing Address - Fax:
Practice Address - Street 1:3832 SW 33RD CT
Practice Address - Street 2:
Practice Address - City:WEST PARK
Practice Address - State:FL
Practice Address - Zip Code:33023-5631
Practice Address - Country:US
Practice Address - Phone:954-947-5061
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2025-08-15
Last Update Date:2025-08-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GARBT-24-391137106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician