Healthcare Provider Details

I. General information

NPI: 1730642638
Provider Name (Legal Business Name): MRS. ROSHEBA HICKMAN-WALLACE
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/09/2019
Last Update Date: 03/03/2026
Certification Date: 03/03/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

304 NW 5TH ST
OKEECHOBEE FL
34972-2565
US

IV. Provider business mailing address

304 NW 5TH ST
OKEECHOBEE FL
34972-2565
US

V. Phone/Fax

Practice location:
  • Phone: 936-714-9375
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code171M00000X
TaxonomyCase Manager/Care Coordinator
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: