Healthcare Provider Details

I. General information

NPI: 1457280828
Provider Name (Legal Business Name): DANA J. WALLACE, LCSW, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/14/2026
Last Update Date: 05/14/2026
Certification Date: 05/13/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

480 SANTA ROSA BLVD UNIT 308E
FORT WALTON BEACH FL
32548-6945
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 Number
License Number State

VIII. Authorized Official

Name: DANA JANELLE WALLACE
Title or Position: SOCIAL WORKER/PSYCHTHERAPIST
Credential: LCSW, LICSW
Phone: 251-421-0712