Provider Demographics
NPI:1396381794
Name:WALLNER, HARLAN DAVID (RMHCI)
Entity Type:Individual
Prefix:
First Name:HARLAN
Middle Name:DAVID
Last Name:WALLNER
Suffix:
Gender:M
Credentials:RMHCI
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2222 HENCYE DR APT B
Mailing Address - Street 2:
Mailing Address - City:PENSACOLA
Mailing Address - State:FL
Mailing Address - Zip Code:32514-7723
Mailing Address - Country:US
Mailing Address - Phone:850-748-6318
Mailing Address - Fax:
Practice Address - Street 1:1101 GULF BREEZE PARKWAY
Practice Address - Street 2:BLDG 5, STE 12
Practice Address - City:GULF BREEZE
Practice Address - State:FL
Practice Address - Zip Code:32561-4892
Practice Address - Country:US
Practice Address - Phone:850-757-3976
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-11-20
Last Update Date:2019-11-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLIMH18079101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental HealthGroup - Single Specialty