MEDICARE: MYISHA L 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	106H00000X	Marriage & Family Therapist	MT5504	FL

General Provider Information

NPI Number	:	1659062891
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MYISHA L WALLACE

Provider Business Mailing Address
First Line	:	7901 4TH ST N STE 300
Second Line	:
City	:	ST PETERSBURG
State	:	FL
Zip	:	33702-4399
Country	:	US
Telephone Number	:	813-520-0156
Fax Number	:

Provider Business Practice Location Address
First Line	:	13190 ROYAL PINES AVE
Second Line	:
City	:	RIVERVIEW
State	:	FL
Zip	:	33579-9321
Country	:	US
Telephone Number	:	813-520-0156
Fax Number	:

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

Provider Enumeration Date	:	05/18/2023
Last Update Date	:	06/06/2026

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