Provider Demographics
NPI:1295899698
Name:WALLACE, DREW D (PHD)
Entity type:Individual
Prefix:DR
First Name:DREW
Middle Name:D
Last Name:WALLACE
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 1:6893 SW 18TH ST
Mailing Address - Street 2:SUITE F-101
Mailing Address - City:BOCA RATON
Mailing Address - State:FL
Mailing Address - Zip Code:33433-7044
Mailing Address - Country:US
Mailing Address - Phone:954-303-6693
Mailing Address - Fax:561-447-7621
Practice Address - Street 1:6893 SW 18TH ST
Practice Address - Street 2:SUITE F-101
Practice Address - City:BOCA RATON
Practice Address - State:FL
Practice Address - Zip Code:33433-7044
Practice Address - Country:US
Practice Address - Phone:954-303-6693
Practice Address - Fax:561-447-7621
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-20
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPY6717103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
DCU0548Medicare ID - Type Unspecified