Individual
MYISHA L WALLACE
Active
Sole proprietor
No
Provider details
NPI number
Gender
F
Contact information
Practice address
13190 ROYAL PINES AVE, RIVERVIEW, FL 33579-9321
(813) 520-0156
Mailing address
13190 ROYAL PINES AVE, RIVERVIEW, FL 33579-9321
(813) 520-0156
Taxonomy
Speciality
Code
Description
License number
State
106H00000X
Marriage & Family Therapist
Primary
IMT3816
FL
Other
Enumeration date
05/18/2023
Last updated
05/18/2023
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