Provider Demographics
NPI:1689483182
Name:WALLACE, DESEAN
Entity type:Individual
Prefix:
First Name:DESEAN
Middle Name:
Last Name:WALLACE
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5203 MATANZAS AVE
Mailing Address - Street 2:
Mailing Address - City:FORT PIERCE
Mailing Address - State:FL
Mailing Address - Zip Code:34946-1002
Mailing Address - Country:US
Mailing Address - Phone:706-832-5640
Mailing Address - Fax:
Practice Address - Street 1:6383 10TH AVE N STE E
Practice Address - Street 2:
Practice Address - City:GREENACRES
Practice Address - State:FL
Practice Address - Zip Code:33463-1689
Practice Address - Country:US
Practice Address - Phone:561-429-5794
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-12-31
Last Update Date:2025-01-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst