Healthcare Provider Details

I. General information

NPI: 1821682121
Provider Name (Legal Business Name): BREANNE WALLIN
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/26/2021
Last Update Date: 02/26/2021
Certification Date: 02/26/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2140 N DON WICKHAM DR
CLERMONT FL
34711-1923
US

IV. Provider business mailing address

PO BOX 491000
LEESBURG FL
34749-1000
US

V. Phone/Fax

Practice location:
  • Phone: 352-394-5922
  • Fax:
Mailing address:
  • Phone: 352-315-7531
  • Fax: 352-315-7587

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License NumberISW15020
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: