Provider Demographics
NPI:1730817149
Name:WALLACE MENTAL HEALTH & ADDICTION COUNSELING LLC
Entity type:Organization
Organization Name:WALLACE MENTAL HEALTH & ADDICTION COUNSELING LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:LICENSED CLINICIAN SOCIAL WORKER
Authorized Official - Prefix:MR
Authorized Official - First Name:REGINAL
Authorized Official - Middle Name:A
Authorized Official - Last Name:WALLACE
Authorized Official - Suffix:
Authorized Official - Credentials:LCSW
Authorized Official - Phone:863-529-3725
Mailing Address - Street 1:1810 SADDLEWOOD PL
Mailing Address - Street 2:
Mailing Address - City:BARTOW
Mailing Address - State:FL
Mailing Address - Zip Code:33830-2917
Mailing Address - Country:US
Mailing Address - Phone:863-529-3725
Mailing Address - Fax:
Practice Address - Street 1:1810 SADDLEWOOD PL
Practice Address - Street 2:
Practice Address - City:BARTOW
Practice Address - State:FL
Practice Address - Zip Code:33830-2917
Practice Address - Country:US
Practice Address - Phone:863-529-3725
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2022-08-12
Last Update Date:2022-08-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinicalGroup - Single Specialty