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General NPI Number Information
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NPI Number | 1629651203
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Entity Type | Individual
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Provider Name | YELDA N WALLACE
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Gender | Female
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Dates
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Enumeration Date | 05/03/2021
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Last Update Date | 03/16/2026
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Provider Practice Location Address
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Address Line | 3825 HENDERSON BLVD STE 406
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City | TAMPA
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State | FL
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Zip | 33629-5022
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Country | US
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Telephone | 813-291-7150
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Fax | 855-318-5403
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Provider Business Mailing Address
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Address Line | 1734 NEVADA AVE NE
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City | SAINT PETERSBURG
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State | FL
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Zip | 33703-3344
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Country | US
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Telephone | 703-981-7069
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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 | 103G00000X
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Taxonomy Name | Clinical Neuropsychologist
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License Number | PY11975
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License Number State | FL
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