Healthcare Provider Details

I. General information

NPI: 1548975808
Provider Name (Legal Business Name): EMILY MARY WALLACE
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/20/2023
Last Update Date: 08/21/2026
Certification Date: 08/21/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

233 DELLA CT
SPRING HILL FL
34606-5358
US

IV. Provider business mailing address

745 ORIENTA AVE STE 1011
ALTAMONTE SPRINGS FL
32701-5675
US

V. Phone/Fax

Practice location:
  • Phone: 877-823-4283
  • Fax: 352-332-8589
Mailing address:
  • Phone: 877-823-4283
  • Fax: 352-332-8589

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code106S00000X
TaxonomyBehavior Technician
License Number
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: