Healthcare Provider Details

I. General information

NPI: 1174173348
Provider Name (Legal Business Name): SHERI ANNE WALLACE LMHC
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/18/2019
Last Update Date: 09/18/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

120 SEA GROVE MAIN ST INSIDE CITY WELLNESS, SECOND FLOOR
ST. AUGUSTINE FL
32080-3208
US

IV. Provider business mailing address

135 JENKINS STREET, STE 105B BOX 144
ST. AUGUSTINE FL
32086
US

V. Phone/Fax

Practice location:
  • Phone: 904-271-5456
  • Fax:
Mailing address:
  • Phone: 904-271-5456
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License NumberMH3003
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: