Provider Demographics
NPI:1922303007
Name:WALLACE, KRISTIN K (LMHC)
Entity type:Individual
Prefix:
First Name:KRISTIN
Middle Name:K
Last Name:WALLACE
Suffix:
Gender:F
Credentials:LMHC
Other - Prefix:
Other - First Name:KRISTEN
Other - Middle Name:
Other - Last Name:KIRBY
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:1250 W EAU GALLIE BLVD STE A
Mailing Address - Street 2:
Mailing Address - City:MELBOURNE
Mailing Address - State:FL
Mailing Address - Zip Code:32935-5385
Mailing Address - Country:US
Mailing Address - Phone:772-361-1413
Mailing Address - Fax:
Practice Address - Street 1:1250 W EAU GALLIE BLVD STE A
Practice Address - Street 2:
Practice Address - City:MELBOURNE
Practice Address - State:FL
Practice Address - Zip Code:32935-5385
Practice Address - Country:US
Practice Address - Phone:772-361-1413
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-01-20
Last Update Date:2025-01-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLIMH7107101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health