Zakary Russell Wallace, MS, BCBA, LBA

Primary specialty

Behavior AnalystTaxonomy code 103K00000X

License

274223 Issued in KY

Practice address

2427 Russellville Rd
Bowling Green, KY 42101-3980

Phone

(270) 936-7472

Fax

(317) 520-8200

NPI assigned

Apr 24, 2019

Sex

Male

Sole proprietor

No

Registry information is reported by the provider to CMS and is not verified. About this source

Specialties & licenses 3

Addresses

Other identifiers 2

Medicare fee-for-service enrollment

Not listed in the public Medicare enrollment file

Medicare enrollment (NPD)

Not enrolled

Credentials

Master of Science

State licenses

Practice roles

Organizations this provider is connected to: Medicare benefit reassignments (the organization bills Medicare for this provider’s services), Care Compare group memberships and National Provider Directory roles.

• Hopebridge, LLC

  • Child & Adolescent Psychiatry Physician
  • Bowling Green, KY
  • NPI 1477071033

  Behavior Analyst

  NPD (past)

The complete NPPES record for this NPI in the NPI Registry API format.

{
    "created_epoch": "1556064000000",
    "enumeration_type": "NPI-1",
    "last_updated_epoch": "1635724800000",
    "number": "1497319529",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "3500 DEPAUW BLVD STE 3070",
            "city": "INDIANAPOLIS",
            "state": "IN",
            "postal_code": "462686135",
            "telephone_number": "855-324-0885",
            "fax_number": "317-520-8200"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "2427 RUSSELLVILLE RD",
            "city": "BOWLING GREEN",
            "state": "KY",
            "postal_code": "421013980",
            "telephone_number": "270-936-7472",
            "fax_number": "317-520-8200"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "last_name": "WALLACE",
        "first_name": "ZAKARY",
        "middle_name": "RUSSELL",
        "credential": "MS, BCBA, LBA",
        "sole_proprietor": "NO",
        "sex": "M",
        "enumeration_date": "2019-04-24",
        "last_updated": "2021-11-01",
        "certification_date": "2021-11-01",
        "status": "A"
    },
    "taxonomies": [
        {
            "code": "103K00000X",
            "taxonomy_group": "",
            "desc": "Behavior Analyst",
            "state": null,
            "license": null,
            "primary": false
        },
        {
            "code": "106S00000X",
            "taxonomy_group": "",
            "desc": "Behavior Technician",
            "state": null,
            "license": "RBT-19-84856",
            "primary": false
        },
        {
            "code": "103K00000X",
            "taxonomy_group": "",
            "desc": "Behavior Analyst",
            "state": "KY",
            "license": "274223",
            "primary": true
        }
    ],
    "identifiers": [
        {
            "code": "01",
            "desc": "Other (non-Medicare)",
            "issuer": "BCBA CERTIFICATE",
            "identifier": "1-21-53785",
            "state": null
        },
        {
            "code": "01",
            "desc": "Other (non-Medicare)",
            "issuer": "RBT",
            "identifier": "RBT-19-84856",
            "state": null
        }
    ],
    "endpoints": [],
    "other_names": []
}

• Kimberly Nicole Walker, OTD
• Phillip G. Walker, APRN
• Thomas Henry Walker
• Danna Kaye Wallace, MSW, CSW, CABIP
• Ellery Caroline Wallace, MS, CCC-SLP
• Lori A. Walton, APRN
• Allyson Ema Waninger, LPCC
• Salem Amari Ward
• Savannah Michelle Young Ward, PA-C
• Trina Rena Warden, OD

• Behavior Analyst in Bowling Green, KY
• Providers in Bowling Green, KY by specialty
• Behavior Analyst in Kentucky

• NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Nov 1, 2021; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
• National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.

Verify at the official NPI Registry.