Provider Demographics
NPI:1073695722
Name:WALLACE, MARTHA E (PT, DPT)
Entity Type:Individual
Prefix:
First Name:MARTHA
Middle Name:E
Last Name:WALLACE
Suffix:
Gender:F
Credentials:PT, DPT
Other - Prefix:
Other - First Name:MARTHA
Other - Middle Name:H
Other - Last Name:RAMIREZ
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:BS,PT
Mailing Address - Street 1:4343 N JOSEY LN
Mailing Address - Street 2:
Mailing Address - City:CARROLLTON
Mailing Address - State:TX
Mailing Address - Zip Code:75010-4603
Mailing Address - Country:US
Mailing Address - Phone:972-394-2232
Mailing Address - Fax:972-512-1570
Practice Address - Street 1:4343 N JOSEY LN
Practice Address - Street 2:
Practice Address - City:CARROLLTON
Practice Address - State:TX
Practice Address - Zip Code:75010-4603
Practice Address - Country:US
Practice Address - Phone:972-394-2232
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-10-20
Last Update Date:2019-12-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAPT00007049225100000X
TX1057529225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist