Provider Demographics
NPI:1063451375
Name:WALLACE, BRIDGETT D'ANN (PT)
Entity Type:Individual
Prefix:
First Name:BRIDGETT
Middle Name:D'ANN
Last Name:WALLACE
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5608 PARKCREST DR
Mailing Address - Street 2:STE 100
Mailing Address - City:AUSTIN
Mailing Address - State:TX
Mailing Address - Zip Code:78731-4972
Mailing Address - Country:US
Mailing Address - Phone:512-345-4664
Mailing Address - Fax:512-345-6150
Practice Address - Street 1:7900 SHOAL CREEK BLVD
Practice Address - Street 2:SUITE 200
Practice Address - City:AUSTIN
Practice Address - State:TX
Practice Address - Zip Code:78757-8037
Practice Address - Country:US
Practice Address - Phone:512-345-4664
Practice Address - Fax:512-345-6150
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-06-05
Last Update Date:2019-01-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX11046102251N0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2251N0400XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistNeurology
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX86683TOtherBCBS INDIVIDUAL #
TX0050HVOtherBCBS GROUP #
TX030384821OtherPHCS PROVIDER #
TX030384821OtherTEXAS TRUE CHOICE
TX030384821OtherHUMANA