MEDICARE: KAREN WALLACE

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	MH22931	FL

General Provider Information

NPI Number	:	1174456834
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	KAREN WALLACE

Provider Business Mailing Address
First Line	:	10855 NW 1ST ST APT 202
Second Line	:
City	:	PEMBROKE PINES
State	:	FL
Zip	:	33026-4092
Country	:	US
Telephone Number	:	305-491-6540
Fax Number	:

Provider Business Practice Location Address
First Line	:	10855 NW 1ST ST APT 202
Second Line	:
City	:	PEMBROKE PINES
State	:	FL
Zip	:	33026-4092
Country	:	US
Telephone Number	:	305-491-6540
Fax Number	:

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

Provider Enumeration Date	:	06/04/2026
Last Update Date	:	06/04/2026

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