MEDICARE: SHENIQUA DONES-WALLACE LMHC

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	101YM0800X	Mental Health Counselor	IMH10688	FL
2	101YM0800X	Mental Health Counselor	MH13004	FL

General Provider Information

NPI Number	:	1063859510
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	SHENIQUA DONES-WALLACE LMHC

Provider Business Mailing Address
First Line	:	1030 NW 178TH TER
Second Line	:
City	:	MIAMI GARDENS
State	:	FL
Zip	:	33169-4173
Country	:	US
Telephone Number	:	786-213-5848
Fax Number	:	954-944-5937

Provider Business Practice Location Address
First Line	:	2500 HOLLYWOOD BLVD STE 104
Second Line	:
City	:	HOLLYWOOD
State	:	FL
Zip	:	33020-6615
Country	:	US
Telephone Number	:	786-353-4622
Fax Number	:	954-944-5937

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

Provider Enumeration Date	:	05/23/2013
Last Update Date	:	09/15/2023

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