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General NPI Number Information
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NPI Number | 1598866071
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Entity Type | Individual
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Provider Name | ROBYN LYNN WALLACE PH.D
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Gender | Female
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Dates
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Enumeration Date | 09/26/2006
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Last Update Date | 10/02/2018
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Provider Practice Location Address
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Address Line | 2141 S ALTERNATE A1A STE 300
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City | JUPITER
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State | FL
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Zip | 33477-4063
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Country | US
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Telephone | 561-301-2908
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Fax |
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Provider Business Mailing Address
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Address Line | 19008 SE LOXAHATCHEE RIVER RD
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City | JUPITER
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State | FL
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Zip | 33458-1072
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Country | US
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Telephone | 561-301-2908
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 103TC0700X
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Taxonomy Name | Clinical Psychologist
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License Number | PY7317
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License Number State | FL
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