Provider Demographics
NPI:1144244179
Name:WALLACE, ALISSA NICOLE (PT)
Entity Type:Individual
Prefix:MRS
First Name:ALISSA
Middle Name:NICOLE
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 1:25590 CORNELL RD
Mailing Address - Street 2:
Mailing Address - City:ARCADIA
Mailing Address - State:IN
Mailing Address - Zip Code:46030-9612
Mailing Address - Country:US
Mailing Address - Phone:317-697-5759
Mailing Address - Fax:
Practice Address - Street 1:25590 CORNELL RD
Practice Address - Street 2:
Practice Address - City:ARCADIA
Practice Address - State:IN
Practice Address - Zip Code:46030-9612
Practice Address - Country:US
Practice Address - Phone:317-697-5759
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-26
Last Update Date:2008-05-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN05006292A225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN200728190Medicaid
IN200630040Medicaid