Healthcare Provider Details

I. General information

NPI: 1730817149
Provider Name (Legal Business Name): WALLACE MENTAL HEALTH & ADDICTION COUNSELING LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/12/2022
Last Update Date: 08/12/2022
Certification Date: 08/12/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1810 SADDLEWOOD PL
BARTOW FL
33830-2917
US

IV. Provider business mailing address

1810 SADDLEWOOD PL
BARTOW FL
33830-2917
US

V. Phone/Fax

Practice location:
  • Phone: 863-529-3725
  • Fax:
Mailing address:
  • Phone: 863-529-3725
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number
License Number State

VIII. Authorized Official

Name: MR. REGINAL A. WALLACE
Title or Position: LICENSED CLINICIAN SOCIAL WORKER
Credential: LCSW
Phone: 863-529-3725