Provider Demographics
NPI:1073671319
Name:WALLACE, MARSHA A (PT)
Entity Type:Individual
Prefix:
First Name:MARSHA
Middle Name:A
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 1:10218 COUNTY ROUTE 92
Mailing Address - Street 2:
Mailing Address - City:WAYLAND
Mailing Address - State:NY
Mailing Address - Zip Code:14572-9418
Mailing Address - Country:US
Mailing Address - Phone:585-728-2079
Mailing Address - Fax:
Practice Address - Street 1:111 CLARA BARTON ST
Practice Address - Street 2:
Practice Address - City:DANSVILLE
Practice Address - State:NY
Practice Address - Zip Code:14437-9503
Practice Address - Country:US
Practice Address - Phone:585-335-4239
Practice Address - Fax:585-335-4295
Is Sole Proprietor?:No
Enumeration Date:2006-12-05
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY4861225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist