Provider Demographics
NPI:1609464098
Name:WALLACE, RAYCHELLE SHERYL
Entity Type:Individual
Prefix:
First Name:RAYCHELLE
Middle Name:SHERYL
Last Name:WALLACE
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11705 BOYETTE RD
Mailing Address - Street 2:PMB 430
Mailing Address - City:RIVERVIEW
Mailing Address - State:FL
Mailing Address - Zip Code:33569
Mailing Address - Country:US
Mailing Address - Phone:813-798-0800
Mailing Address - Fax:
Practice Address - Street 1:673 W LUMSDEN RD
Practice Address - Street 2:
Practice Address - City:BRANDON
Practice Address - State:FL
Practice Address - Zip Code:33511-5911
Practice Address - Country:US
Practice Address - Phone:813-798-0800
Practice Address - Fax:813-798-7800
Is Sole Proprietor?:Yes
Enumeration Date:2021-01-02
Last Update Date:2023-08-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLIMH18337251S00000X, 261QM0801X, 251B00000X, 261QM0850X, 261QM0855X
FLMH19813101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No251S00000XAgenciesCommunity/Behavioral Health
No261QM0801XAmbulatory Health Care FacilitiesClinic/CenterMental Health (Including Community Mental Health Center)
No251B00000XAgenciesCase Management
No261QM0850XAmbulatory Health Care FacilitiesClinic/CenterAdult Mental Health
No261QM0855XAmbulatory Health Care FacilitiesClinic/CenterAdolescent and Children Mental Health