=====================================================
General NPI Number Information
=====================================================
NPI Number | 1770075228
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | WALLACE DASHER III MS
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 05/31/2018
-----------------------------------------------------
Last Update Date | 01/31/2019
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1703 W COLONIAL DR
-----------------------------------------------------
City | ORLANDO
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 32804-7000
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 321-332-8211
-----------------------------------------------------
Fax | 248-769-6154
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 332 FRIARS LN
-----------------------------------------------------
City | LAKE MARY
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 32746-3459
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 941-404-8382
-----------------------------------------------------
Fax | 248-769-6154
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 101Y00000X
-----------------------------------------------------
Taxonomy Name | Counselor
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 101YA0400X
-----------------------------------------------------
Taxonomy Name | Addiction (Substance Use Disorder) Counselor
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #3
-----------------------------------------------------
Taxonomy Code | 101YS0200X
-----------------------------------------------------
Taxonomy Name | School Counselor
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #4
-----------------------------------------------------
Taxonomy Code | 102L00000X
-----------------------------------------------------
Taxonomy Name | Psychoanalyst
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #5
-----------------------------------------------------
Taxonomy Code | 101YM0800X
-----------------------------------------------------
Taxonomy Name | Mental Health Counselor
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------