Provider Demographics
NPI:1275562753
Name:WALLACE, JULIE M (PT)
Entity Type:Individual
Prefix:MRS
First Name:JULIE
Middle Name:M
Last Name:WALLACE
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:JULIE
Other - Middle Name:M
Other - Last Name:NORTHROP
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:PT
Mailing Address - Street 1:510 TOWNE DR
Mailing Address - Street 2:SUITE 100
Mailing Address - City:FAYETTEVILLE
Mailing Address - State:NY
Mailing Address - Zip Code:13066-1331
Mailing Address - Country:US
Mailing Address - Phone:315-637-4747
Mailing Address - Fax:305-637-6711
Practice Address - Street 1:510 TOWNE DR
Practice Address - Street 2:SUITE 100
Practice Address - City:FAYETTEVILLE
Practice Address - State:NY
Practice Address - Zip Code:13066-1331
Practice Address - Country:US
Practice Address - Phone:315-637-4747
Practice Address - Fax:305-637-6711
Is Sole Proprietor?:No
Enumeration Date:2006-06-30
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY027181-1225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY000928255001OtherHEALTHNOW NY
NY4145929OtherMVP
NY5056028OtherAETNA
NY5056028OtherAETNA