Healthcare Provider Details

I. General information

NPI: 1174456834
Provider Name (Legal Business Name): KAREN WALLACE
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/04/2026
Last Update Date: 06/04/2026
Certification Date: 06/03/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

10855 NW 1ST ST APT 202
PEMBROKE PINES FL
33026-4092
US

IV. Provider business mailing address

10855 NW 1ST ST APT 202
PEMBROKE PINES FL
33026-4092
US

V. Phone/Fax

Practice location:
  • Phone: 305-491-6540
  • Fax:
Mailing address:
  • Phone: 305-491-6540
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License NumberMH22931
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: