Provider Demographics
NPI:1841656311
Name:WALLACE, MELISSA EMILY (LCSW)
Entity type:Individual
Prefix:
First Name:MELISSA
Middle Name:EMILY
Last Name:WALLACE
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:MELISSA
Other - Middle Name:EMILY
Other - Last Name:MARTINEZ
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:6700 S FLORIDA AVE STE 33
Mailing Address - Street 2:
Mailing Address - City:LAKELAND
Mailing Address - State:FL
Mailing Address - Zip Code:33813-3312
Mailing Address - Country:US
Mailing Address - Phone:863-450-3067
Mailing Address - Fax:863-337-4123
Practice Address - Street 1:1473 CYPRESS VIEW LN
Practice Address - Street 2:
Practice Address - City:LAKELAND
Practice Address - State:FL
Practice Address - Zip Code:33811-2689
Practice Address - Country:US
Practice Address - Phone:863-899-7613
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-01-13
Last Update Date:2023-02-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLSW174701041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical