Provider Demographics
NPI:1346076767
Name:WALLECK, PHILLIP (PHD)
Entity type:Individual
Prefix:
First Name:PHILLIP
Middle Name:
Last Name:WALLECK
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:174 WATERCOLOR WAY # 103-238
Mailing Address - Street 2:
Mailing Address - City:SANTA ROSA BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:32459-7350
Mailing Address - Country:US
Mailing Address - Phone:850-660-8353
Mailing Address - Fax:
Practice Address - Street 1:174 WATERCOLOR WAY # 103-238
Practice Address - Street 2:
Practice Address - City:SANTA ROSA BEACH
Practice Address - State:FL
Practice Address - Zip Code:32459-7350
Practice Address - Country:US
Practice Address - Phone:850-660-8353
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-09-11
Last Update Date:2024-09-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP1600XBehavioral Health & Social Service ProvidersCounselorPastoral