Kristen Nicole Wallace

Primary specialty

Behavior AnalystTaxonomy code 103K00000X

License

1-21-51057 Issued in NC

Practice address

834 Tyvola Rd Ste 126
Charlotte, NC 28217-3598

Phone

(980) 785-1113

Fax

(980) 785-1114

NPI assigned

Jul 3, 2021

Last updated

Jul 24, 2024By the provider in NPPES

Sex

Female

Sole proprietor

No

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

Specialties & licenses 1

Addresses

Medicare fee-for-service enrollment

Not listed in the public Medicare enrollment file

Medicare enrollment (NPD)

Not enrolled

Practice roles

Locations

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

• Mosaic Group, LLC

  dba Mosaic Pediatric Therapy

  • Behavior Analyst
  • Pineville, NC
  • NPI 1144682873
  NPD

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

{
    "created_epoch": "1625270400000",
    "enumeration_type": "NPI-1",
    "last_updated_epoch": "1721779200000",
    "number": "1619548336",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "2810 COLISEUM CENTRE DR STE 520",
            "city": "CHARLOTTE",
            "state": "NC",
            "postal_code": "282173252",
            "telephone_number": "980-785-1113",
            "fax_number": "980-785-1114"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "834 TYVOLA RD STE 126",
            "city": "CHARLOTTE",
            "state": "NC",
            "postal_code": "282173598",
            "telephone_number": "980-785-1113",
            "fax_number": "980-785-1114"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "last_name": "WALLACE",
        "first_name": "KRISTEN",
        "middle_name": "NICOLE",
        "sole_proprietor": "NO",
        "sex": "F",
        "enumeration_date": "2021-07-03",
        "last_updated": "2024-07-24",
        "certification_date": "2024-07-22",
        "status": "A"
    },
    "taxonomies": [
        {
            "code": "103K00000X",
            "taxonomy_group": "",
            "desc": "Behavior Analyst",
            "state": "NC",
            "license": "1-21-51057",
            "primary": true
        }
    ],
    "identifiers": [],
    "endpoints": [],
    "other_names": []
}

• James William Wallace, M.D.
• Jill Marie Wallace, N.P.
• Joyce W Wallace, LCSW, LISW-CP
• Kayla Wallace
• Khaira-Nisaa Hicks Wallace
• Lacey L Wallace
• Lester B. Wallace Jr., MD
• Monica M. Wallace, LCSW
• Noah Wallace
• Portia Dionne Wallace

• Behavior Analyst in Charlotte, NC
• Providers in Charlotte, NC by specialty
• Behavior Analyst in North Carolina

• NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Jul 24, 2024; 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.