Provider Demographics
NPI:1053849802
Name:WALLACE, STEPHEN PADEN (PT, DPT)
Entity Type:Individual
Prefix:
First Name:STEPHEN
Middle Name:PADEN
Last Name:WALLACE
Suffix:
Gender:M
Credentials:PT, DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8823 PRODUCTION LN
Mailing Address - Street 2:
Mailing Address - City:OOLTEWAH
Mailing Address - State:TN
Mailing Address - Zip Code:37363-6511
Mailing Address - Country:US
Mailing Address - Phone:423-238-7217
Mailing Address - Fax:423-362-8684
Practice Address - Street 1:925 GARRETT ST SE STE J
Practice Address - Street 2:
Practice Address - City:ATLANTA
Practice Address - State:GA
Practice Address - Zip Code:30316-6833
Practice Address - Country:US
Practice Address - Phone:404-624-5407
Practice Address - Fax:404-624-5409
Is Sole Proprietor?:No
Enumeration Date:2017-05-24
Last Update Date:2019-09-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAPT012936225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist