Provider Demographics
NPI:1043866411
Name:WALLACE, WANDA DANNETTE (DSW, LCSW)
Entity Type:Individual
Prefix:DR
First Name:WANDA
Middle Name:DANNETTE
Last Name:WALLACE
Suffix:
Gender:F
Credentials:DSW, LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9013 UNIVERSITY PKWY STE C
Mailing Address - Street 2:
Mailing Address - City:PENSACOLA
Mailing Address - State:FL
Mailing Address - Zip Code:32514-9421
Mailing Address - Country:US
Mailing Address - Phone:850-380-8320
Mailing Address - Fax:850-478-7802
Practice Address - Street 1:9013 UNIVERSITY PKWY STE C
Practice Address - Street 2:
Practice Address - City:PENSACOLA
Practice Address - State:FL
Practice Address - Zip Code:32514-9421
Practice Address - Country:US
Practice Address - Phone:850-380-8320
Practice Address - Fax:850-478-7802
Is Sole Proprietor?:No
Enumeration Date:2019-08-12
Last Update Date:2019-08-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLSW139391041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical