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NPI Code Detail

MEDICARE: MR. WALLACE SCOTT SHEARON LMFT

MEDICARE: MR. WALLACE SCOTT SHEARON LMFT
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
1101YM0800XMental Health CounselorMT1767FL

Other Identifiers

# Provider Identifier Provider Identifier Type Provider Identifier State Provider Identifier Issuer
1MT1767OTHERFLMARRIAGE AND FAMILY THERAPIST
2MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number : 1568422533
Entity Type Code : Individual
Provider Name (Legal Business Name) : MR. WALLACE SCOTT SHEARON LMFT
Provider Business Mailing Address
First Line : 565 MEMORIAL CIR
Second Line :
City : ORMOND BEACH
State : FL
Zip : 32174-5001
Country : US
Telephone Number : 386-310-8766
Fax Number : 386-310-8770
Provider Business Practice Location Address
First Line : 565 MEMORIAL CIR
Second Line :
City : ORMOND BEACH
State : FL
Zip : 32174-5001
Country : US
Telephone Number : 386-310-8766
Fax Number : 386-310-8770
Authorized Official
Title or Position :
Name :
Credential :
Telephone Number :
Provider Enumeration Date : 03/24/2006
Last Update Date : 12/16/2019

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