MEDICARE: DANIELLE LASKEY WALLACE MS, CCC-SLP

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	235Z00000X	Speech-Language Pathologist	SA14028	FL

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1053712661
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DANIELLE LASKEY WALLACE MS, CCC-SLP

Provider Business Mailing Address
First Line	:	2401 COUNTRY OAKS LN
Second Line	:
City	:	WEST PALM BEACH
State	:	FL
Zip	:	33410-2009
Country	:	US
Telephone Number	:	561-862-7793
Fax Number	:

Provider Business Practice Location Address
First Line	:	2401 COUNTRY OAKS LN
Second Line	:
City	:	WEST PALM BEACH
State	:	FL
Zip	:	33410-2009
Country	:	US
Telephone Number	:	561-862-7793
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	09/15/2014
Last Update Date	:	06/05/2020

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