Healthcare Provider Details

I. General information

NPI: 1770075228
Provider Name (Legal Business Name): WALLACE DASHER III MS
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/31/2018
Last Update Date: 01/31/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1703 W COLONIAL DR
ORLANDO FL
32804-7000
US

IV. Provider business mailing address

332 FRIARS LN
LAKE MARY FL
32746-3459
US

V. Phone/Fax

Practice location:
  • Phone: 321-332-8211
  • Fax: 248-769-6154
Mailing address:
  • Phone: 941-404-8382
  • Fax: 248-769-6154

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101Y00000X
TaxonomyCounselor
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code101YS0200X
TaxonomySchool Counselor
License Number
License Number State
# 4
Primary TaxonomyN
Taxonomy Code102L00000X
TaxonomyPsychoanalyst
License Number
License Number State
# 5
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: