Active NPI
Yideira Wallace, RBT
- Behavior Technician
- North Port, FL
National Provider Identifier
1073264289
On this page
Key facts
NPPES NPI Registry- Primary specialty
- Behavior Technician
- License
- RBT-21-195063
- Practice address
- 4584 Flint Dr
North Port, FL 34286-6604 - Phone
- (786) 570-3643
- NPI assigned
- Jan 10, 2022
- Sex
- Female
- Sole proprietor
- Yes
NPPES NPI Registry
Registry information is reported by the provider to CMS and is not verified. About this source
Specialties & licenses 1
| Specialty (taxonomy) | Code | License | State | Primary |
|---|---|---|---|---|
| Behavior Technician | 106S00000X | RBT-21-195063 | FL | Primary |
Addresses
Primary practice location
4584 Flint Dr
North Port, FL 34286-6604
Mailing address
4584 Flint Dr
North Port, FL 34286-6604
Phone (786) 570-3643
Medicare participation
Medicare enrollment files- Medicare fee-for-service enrollment
- Not listed in the public Medicare enrollment file
National Provider Directory
National Provider Directory- Medicare enrollment (NPD)
- Not enrolled
State licenses
| License | State | Type | Specialty |
|---|---|---|---|
| RBT-21-195063 | FL | MD | Behavior Technician |
NPI Registry JSON
The complete NPPES record for this NPI in the NPI Registry API format.
{
"created_epoch": "1641772800000",
"enumeration_type": "NPI-1",
"last_updated_epoch": "1641772800000",
"number": "1073264289",
"addresses": [
{
"country_code": "US",
"country_name": "United States",
"address_purpose": "MAILING",
"address_type": "DOM",
"address_1": "4584 FLINT DR",
"city": "NORTH PORT",
"state": "FL",
"postal_code": "342866604",
"telephone_number": "786-570-3643"
},
{
"country_code": "US",
"country_name": "United States",
"address_purpose": "LOCATION",
"address_type": "DOM",
"address_1": "4584 FLINT DR",
"city": "NORTH PORT",
"state": "FL",
"postal_code": "342866604",
"telephone_number": "786-570-3643"
}
],
"practiceLocations": [],
"basic": {
"last_name": "WALLACE",
"first_name": "YIDEIRA",
"name_prefix": "Mrs.",
"credential": "RBT",
"sole_proprietor": "YES",
"sex": "F",
"enumeration_date": "2022-01-10",
"last_updated": "2022-01-10",
"certification_date": "2022-01-10",
"status": "A"
},
"taxonomies": [
{
"code": "106S00000X",
"taxonomy_group": "",
"desc": "Behavior Technician",
"state": "FL",
"license": "RBT-21-195063",
"primary": true
}
],
"identifiers": [],
"endpoints": [],
"other_names": []
}Other providers in North Port, FL
Sources for this page
- NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Jan 10, 2022; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
- National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.