Healthcare Provider Details

I. General information

NPI: 1255257648
Provider Name (Legal Business Name): SEASONS WELLHAUS LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/29/2026
Last Update Date: 06/29/2026
Certification Date: 06/29/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7901 4TH ST N STE 400
ST PETERSBURG FL
33702-4305
US

IV. Provider business mailing address

7901 4TH ST N STE 400
ST PETERSBURG FL
33702-4305
US

V. Phone/Fax

Practice location:
  • Phone: 813-520-0156
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code106H00000X
TaxonomyMarriage & Family Therapist
License Number
License Number State

VIII. Authorized Official

Name: MYISHA LISHA WALLACE
Title or Position: LMFT/OWNER
Credential: LMFT
Phone: 815-520-0156