| Doctor Name: | JOHANNA WALLACE |
| NPI Number: | 1942406723 |
| Entity Type Code: | Individual (1) |
| Gender: | M |
| Credentials: | MS CCC-SLP |
| License Number: | SA8966 |
| Business Practice Address: | 10125 Vixen Pl Pensacola, FL - 325147137 |
| Business Phone Number: | 8505120156 |
| Business Fax Number: | |
| Mailing Address: | 10125 Vixen Pl, PENSACOLA |
| State: | FL |
| Postal Code: | 325147137 |
| Phone Number: | 8505120156 |
| Fax Number: | |
| NPI Enumeration Date: | 06/26/2007 |
| NPI Last Update Date: | 07/08/2007 |
| Replacement NPI: | 0 |
| NPI Deactivation Date: | |
| NPI Reactivation Date: |
Taxonomy Information: | |
| Healthcare Provider Taxonomy: | 235Z00000X |
| License Number: | SA8966 |
| Healthcare Provider Taxonomy: (Secondary) | Y |
| State: | FL |
| Taxonomy Type: | Speech, Language and Hearing Service Providers |
| Taxonomy Classification: | Speech-Language Pathologist |
| Taxonomy Specialization: | |
| Taxonomy Definition: | A speech pathologist is a person qualified by a master |