Provider Demographics
NPI:1114003704
Name:WALLACE, SHARI J (PT)
Entity Type:Individual
Prefix:
First Name:SHARI
Middle Name:J
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 1:60 SHUFORD RD
Mailing Address - Street 2:
Mailing Address - City:COLUMBUS
Mailing Address - State:NC
Mailing Address - Zip Code:28722-7406
Mailing Address - Country:US
Mailing Address - Phone:828-894-0277
Mailing Address - Fax:828-894-0278
Practice Address - Street 1:535 LAURENS RD
Practice Address - Street 2:
Practice Address - City:WOODRUFF
Practice Address - State:SC
Practice Address - Zip Code:29388-2209
Practice Address - Country:US
Practice Address - Phone:864-476-6600
Practice Address - Fax:864-476-3514
Is Sole Proprietor?:No
Enumeration Date:2006-10-27
Last Update Date:2016-08-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC3699225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
SCE4361OtherMEDCOST
SCTH1606Medicaid
SC9799717OtherCIGNA
SCQ33477Medicare UPIN
SC7761758OtherAETNA