Provider Demographics
NPI:1194817445
Name:WALLICK, SARENE MALCHA (LCSW)
Entity Type:Individual
Prefix:MS
First Name:SARENE
Middle Name:MALCHA
Last Name:WALLICK
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1056 GORE DR
Mailing Address - Street 2:
Mailing Address - City:OVIEDO
Mailing Address - State:FL
Mailing Address - Zip Code:32765-7058
Mailing Address - Country:US
Mailing Address - Phone:407-927-9718
Mailing Address - Fax:
Practice Address - Street 1:375 DOUGLAS AVE STE 2005
Practice Address - Street 2:
Practice Address - City:ALTAMONTE SPRINGS
Practice Address - State:FL
Practice Address - Zip Code:32714-3315
Practice Address - Country:US
Practice Address - Phone:407-529-5359
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-28
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLSW72321041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical