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Individual

JOHN D WALLACE

Active
Sole proprietor
Yes

Provider details

NPI number
Gender
Man

Contact information

Practice address
1455 NW 53RD ST APT 222, MIAMI, FL 33142
(904) 418-3893
Mailing address
15286 SW 104TH ST APT 2-22, MIAMI, FL 33196-3238
(904) 418-3893

Taxonomy

Speciality
Code
Description
License number
State
101YM0800X
Mental Health Counselor
372600000X
Adult Companion
235276
FL
376J00000X
Homemaker
Primary
235276
FL
385H00000X
Respite Care
235276
FL

Other

Enumeration date
09/30/2013
Last updated
06/29/2018
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