Provider Demographics
NPI:1881556561
Name:WALLACE, ANGENETT (RBT)
Entity type:Individual
Prefix:
First Name:ANGENETT
Middle Name:
Last Name:WALLACE
Suffix:
Gender:F
Credentials:RBT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4559 HEARTLAND DR
Mailing Address - Street 2:
Mailing Address - City:RICHTON PARK
Mailing Address - State:IL
Mailing Address - Zip Code:60471-2413
Mailing Address - Country:US
Mailing Address - Phone:708-762-2907
Mailing Address - Fax:
Practice Address - Street 1:4559 HEARTLAND DR
Practice Address - Street 2:
Practice Address - City:RICHTON PARK
Practice Address - State:IL
Practice Address - Zip Code:60471-2413
Practice Address - Country:US
Practice Address - Phone:708-762-2907
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2025-12-01
Last Update Date:2025-12-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician