Raychelle Sheryl Wallace

Primary specialty

Mental Health CounselorTaxonomy code 101YM0800X

License

MH19813 Issued in FL

Practice address

673 W Lumsden Rd
Brandon, FL 33511-5911

Phone

(813) 798-0800

Fax

(813) 798-7800

NPI assigned

Jan 2, 2021

Sex

Female

Sole proprietor

Yes

Registry information is reported by the provider to CMS and is not verified. About this source

Specialties & licenses 6

Addresses

Medicare fee-for-service enrollment

Not listed in the public Medicare enrollment file

Medicare enrollment (NPD)

Not enrolled

State licenses

The complete NPPES record for this NPI in the NPI Registry API format.

{
    "created_epoch": "1609545600000",
    "enumeration_type": "NPI-1",
    "last_updated_epoch": "1691971200000",
    "number": "1609464098",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "11705 BOYETTE RD",
            "address_2": "PMB 430",
            "city": "RIVERVIEW",
            "state": "FL",
            "postal_code": "33569",
            "telephone_number": "813-798-0800"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "673 W LUMSDEN RD",
            "city": "BRANDON",
            "state": "FL",
            "postal_code": "335115911",
            "telephone_number": "813-798-0800",
            "fax_number": "813-798-7800"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "last_name": "WALLACE",
        "first_name": "RAYCHELLE",
        "middle_name": "SHERYL",
        "sole_proprietor": "YES",
        "sex": "F",
        "enumeration_date": "2021-01-02",
        "last_updated": "2023-08-14",
        "certification_date": "2023-08-12",
        "status": "A"
    },
    "taxonomies": [
        {
            "code": "251S00000X",
            "taxonomy_group": "",
            "desc": "Community/Behavioral Health",
            "state": "FL",
            "license": "IMH18337",
            "primary": false
        },
        {
            "code": "261QM0801X",
            "taxonomy_group": "",
            "desc": "Clinic/Center, Mental Health (Including Community Mental Health Center)",
            "state": "FL",
            "license": "IMH18337",
            "primary": false
        },
        {
            "code": "251B00000X",
            "taxonomy_group": "",
            "desc": "Case Management",
            "state": "FL",
            "license": "IMH18337",
            "primary": false
        },
        {
            "code": "261QM0850X",
            "taxonomy_group": "",
            "desc": "Clinic/Center, Adult Mental Health",
            "state": "FL",
            "license": "IMH18337",
            "primary": false
        },
        {
            "code": "261QM0855X",
            "taxonomy_group": "",
            "desc": "Clinic/Center, Adolescent and Children Mental Health",
            "state": "FL",
            "license": "IMH18337",
            "primary": false
        },
        {
            "code": "101YM0800X",
            "taxonomy_group": "",
            "desc": "Counselor, Mental Health",
            "state": "FL",
            "license": "MH19813",
            "primary": true
        }
    ],
    "identifiers": [],
    "endpoints": [],
    "other_names": []
}

• Majuanna Walker
• Melissa Walker
• Amanda Denise Wallace, NP
• Aster Wallace, RBT
• Johntavia Wallace
• Jared John Wallen, M.D.
• Rebecca Wallington
• Carey J Walls IV
• Darlene Walsh
• Kelly Walsh, LPTA

• Mental Health Counselor in Brandon, FL
• Providers in Brandon, FL by specialty
• Mental Health Counselor in Florida

• NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Aug 14, 2023; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
• National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.

Verify at the official NPI Registry.