| Doctor Name: | MR. DAVID AVERRE WALLACE |
| NPI Number: | 1194723684 |
| Entity Type Code: | Individual (1) |
| Gender: | M |
| Credentials: | M.S. |
| License Number: | 2472 |
| Business Practice Address: | 2194 Main St Suite P Dunedin, FL - 346985696 |
| Business Phone Number: | 7272043395 |
| Business Fax Number: | 8668768484 |
| Mailing Address: | 2194 Main St, Suite P DUNEDIN |
| State: | FL |
| Postal Code: | 346985696 |
| Phone Number: | 7272043395 |
| Fax Number: | 8668768484 |
| NPI Enumeration Date: | 07/08/2005 |
| NPI Last Update Date: | 07/08/2007 |
| Replacement NPI: | 0 |
| NPI Deactivation Date: | |
| NPI Reactivation Date: |
Taxonomy Information: | |
| Healthcare Provider Taxonomy: | 101YA0400X |
| License Number: | 2472 |
| Healthcare Provider Taxonomy: (Secondary) | X |
| State: | FL |
| Taxonomy Type: | Behavioral Health & Social Service Providers |
| Taxonomy Classification: | Counselor |
| Taxonomy Specialization: | Addiction (Substance Use Disorder) |
| Taxonomy Definition: | |