Provider Demographics
NPI:1114469061
Name:WALLACE, SIRENA
Entity Type:Individual
Prefix:
First Name:SIRENA
Middle Name:
Last Name:WALLACE
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5855 MILTON ST
Mailing Address - Street 2:
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75206-4202
Mailing Address - Country:US
Mailing Address - Phone:469-310-1700
Mailing Address - Fax:469-310-1701
Practice Address - Street 1:5100 ELDORADO PKWY
Practice Address - Street 2:#102-20TRLL
Practice Address - City:MCKINNEY
Practice Address - State:TX
Practice Address - Zip Code:75070-6510
Practice Address - Country:US
Practice Address - Phone:469-310-1700
Practice Address - Fax:469-310-1701
Is Sole Proprietor?:No
Enumeration Date:2016-11-09
Last Update Date:2016-11-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX2087653225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant