Provider Demographics
NPI:1174025985
Name:WALLACE, ANTHONY (MASTER)
Entity Type:Individual
Prefix:MR
First Name:ANTHONY
Middle Name:
Last Name:WALLACE
Suffix:
Gender:M
Credentials:MASTER
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2222 PONCE DE LEON BLVD FL 3
Mailing Address - Street 2:
Mailing Address - City:CORAL GABLES
Mailing Address - State:FL
Mailing Address - Zip Code:33134-5039
Mailing Address - Country:US
Mailing Address - Phone:866-305-7365
Mailing Address - Fax:
Practice Address - Street 1:2222 PONCE DE LEON BLVD FL 3
Practice Address - Street 2:
Practice Address - City:CORAL GABLES
Practice Address - State:FL
Practice Address - Zip Code:33134-5039
Practice Address - Country:US
Practice Address - Phone:866-305-7365
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-03-07
Last Update Date:2018-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health