Provider Demographics
NPI:1740981828
Name:WALLACE, TABITHA LACIE (MS, CCC-SLP)
Entity type:Individual
Prefix:MRS
First Name:TABITHA
Middle Name:LACIE
Last Name:WALLACE
Suffix:
Gender:F
Credentials:MS, CCC-SLP
Other - Prefix:MRS
Other - First Name:TABITHA
Other - Middle Name:
Other - Last Name:COLLINS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:5300 LAFAYETTE AVE
Mailing Address - Street 2:
Mailing Address - City:SEBRING
Mailing Address - State:FL
Mailing Address - Zip Code:33875-5686
Mailing Address - Country:US
Mailing Address - Phone:863-414-5207
Mailing Address - Fax:
Practice Address - Street 1:5300 LAFAYETTE AVE
Practice Address - Street 2:
Practice Address - City:SEBRING
Practice Address - State:FL
Practice Address - Zip Code:33875-5686
Practice Address - Country:US
Practice Address - Phone:863-414-5207
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-03-15
Last Update Date:2023-03-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist