Provider Demographics
NPI:1699948844
Name:WALLACE, HOLLY (LMHC)
Entity type:Individual
Prefix:
First Name:HOLLY
Middle Name:
Last Name:WALLACE
Suffix:
Gender:F
Credentials:LMHC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 1559
Mailing Address - Street 2:
Mailing Address - City:BARTOW
Mailing Address - State:FL
Mailing Address - Zip Code:33831-1559
Mailing Address - Country:US
Mailing Address - Phone:863-519-0575
Mailing Address - Fax:
Practice Address - Street 1:1968 SEBRING PKWY
Practice Address - Street 2:
Practice Address - City:SEBRING
Practice Address - State:FL
Practice Address - Zip Code:33870-1654
Practice Address - Country:US
Practice Address - Phone:863-519-0575
Practice Address - Fax:863-582-9251
Is Sole Proprietor?:No
Enumeration Date:2008-04-09
Last Update Date:2015-10-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLMH9182101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL002054100Medicaid