Provider Demographics
NPI:1841234101
Name:WALLACE, KERRY L (LMHC, NCC)
Entity Type:Individual
Prefix:PROF
First Name:KERRY
Middle Name:L
Last Name:WALLACE
Suffix:
Gender:F
Credentials:LMHC, NCC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1841 CROWLEY CIR E
Mailing Address - Street 2:
Mailing Address - City:LONGWOOD
Mailing Address - State:FL
Mailing Address - Zip Code:32779-7016
Mailing Address - Country:US
Mailing Address - Phone:407-333-0254
Mailing Address - Fax:407-333-1231
Practice Address - Street 1:661 SEMINOLA BLVD
Practice Address - Street 2:
Practice Address - City:CASSELBERRY
Practice Address - State:FL
Practice Address - Zip Code:32707-3057
Practice Address - Country:US
Practice Address - Phone:407-333-0254
Practice Address - Fax:407-333-1231
Is Sole Proprietor?:Yes
Enumeration Date:2006-06-16
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLMH 5283101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health