MEDICARE: MRS. INDIRA MARIA WALLACE HARRIS LCSW

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	1041C0700X	Clinical Social Worker	SW 7536	FL

General Provider Information

NPI Number	:	1679637391
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MRS. INDIRA MARIA WALLACE HARRIS LCSW

Provider Business Mailing Address
First Line	:	1373 SW GRANVILLE AVE
Second Line	:
City	:	PORT ST LUCIE
State	:	FL
Zip	:	34953-2202
Country	:	US
Telephone Number	:	954-347-6095
Fax Number	:

Provider Business Practice Location Address
First Line	:	727 N US HIGHWAY 1
Second Line	:
City	:	FORT PIERCE
State	:	FL
Zip	:	34950-9125
Country	:	US
Telephone Number	:	772-595-5150
Fax Number	:

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

Provider Enumeration Date	:	12/20/2006
Last Update Date	:	07/08/2007

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