Healthcare Provider Details

I. General information

NPI: 1477063410
Provider Name (Legal Business Name): KASIE WALLACE MA, LMHC, QS
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/04/2017
Last Update Date: 12/19/2025
Certification Date: 12/19/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

420 RIDGEWOOD ST
ALTAMONTE SPRINGS FL
32701-7822
US

IV. Provider business mailing address

420 RIDGEWOOD ST
ALTAMONTE SPRINGS FL
32701-7822
US

V. Phone/Fax

Practice location:
  • Phone: 407-205-7584
  • Fax:
Mailing address:
  • Phone: 407-205-7584
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License NumberMH17915
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: