MEDICARE: SERGIO 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	106S00000X	Behavior Technician

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	:	1720525728
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	SERGIO WALLACE

Provider Business Mailing Address
First Line	:	8201 CANTERBURY LAKE BLVD
Second Line	:
City	:	TAMPA
State	:	FL
Zip	:	33619-6671
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	8201 CANTERBURY LAKE BLVD
Second Line	:
City	:	TAMPA
State	:	FL
Zip	:	33619-6671
Country	:	US
Telephone Number	:	727-657-8299
Fax Number	:

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

Provider Enumeration Date	:	01/27/2017
Last Update Date	:	01/27/2017

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