Healthcare Provider Details

I. General information

NPI: 1144747205
Provider Name (Legal Business Name): DANA WALLACE LCSW, LICSW
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/29/2017
Last Update Date: 05/06/2026
Certification Date: 05/06/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

480 SANTA ROSA BLVD
FORT WALTON BEACH FL
32548-6901
US

IV. Provider business mailing address

480 SANTA ROSA BLVD UNIT 308E
FORT WALTON BEACH FL
32548-6945
US

V. Phone/Fax

Practice location:
  • Phone: 251-421-0712
  • Fax:
Mailing address:
  • Phone: 251-421-0712
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License NumberSW24920
License Number StateFL
# 2
Primary TaxonomyN
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number6143C
License Number StateAL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: