Provider Demographics
NPI:1316282205
Name:WALLACE, DAVINA (MS,CCC-SLP)
Entity type:Individual
Prefix:
First Name:DAVINA
Middle Name:
Last Name:WALLACE
Suffix:
Gender:F
Credentials:MS,CCC-SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:13014 N DALE MABRY HWY STE 659
Mailing Address - Street 2:
Mailing Address - City:TAMPA
Mailing Address - State:FL
Mailing Address - Zip Code:33618-2808
Mailing Address - Country:US
Mailing Address - Phone:813-215-6275
Mailing Address - Fax:813-852-6373
Practice Address - Street 1:12768 WOOD TRAIL BLVD
Practice Address - Street 2:
Practice Address - City:TAMPA
Practice Address - State:FL
Practice Address - Zip Code:33625-5905
Practice Address - Country:US
Practice Address - Phone:813-215-6275
Practice Address - Fax:866-636-0443
Is Sole Proprietor?:Yes
Enumeration Date:2012-12-03
Last Update Date:2020-12-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
222Q00000X
FLSA3018235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
No222Q00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersDevelopmental Therapist