MEDICARE: DANA J. WALLACE, LCSW, LLC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	1041C0700X	Clinical Social Worker

General Provider Information

NPI Number	:	1457280828
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	DANA J. WALLACE, LCSW, LLC

Provider Business Mailing Address
First Line	:	480 SANTA ROSA BLVD UNIT 308E
Second Line	:
City	:	FORT WALTON BEACH
State	:	FL
Zip	:	32548-6945
Country	:	US
Telephone Number	:	251-421-0712
Fax Number	:

Provider Business Practice Location Address
First Line	:	480 SANTA ROSA BLVD UNIT 308E
Second Line	:
City	:	FORT WALTON BEACH
State	:	FL
Zip	:	32548-6945
Country	:	US
Telephone Number	:	251-421-0712
Fax Number	:

Authorized Official
Title or Position	:	SOCIAL WORKER/PSYCHTHERAPIST
Name	:	DANA JANELLE WALLACE
Credential	:	LCSW, LICSW
Telephone Number	:	251-421-0712

Provider Enumeration Date	:	05/14/2026
Last Update Date	:	05/14/2026

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