Provider Demographics
NPI:1326647447
Name:WALLACE, LAURALEE
Entity Type:Individual
Prefix:
First Name:LAURALEE
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 1:11239 BALL MTN LITTLE SHASTA RD
Mailing Address - Street 2:
Mailing Address - City:MONTAGUE
Mailing Address - State:CA
Mailing Address - Zip Code:96064-9682
Mailing Address - Country:US
Mailing Address - Phone:530-340-1490
Mailing Address - Fax:
Practice Address - Street 1:11239 BALL MTN LITTLE SHASTA RD
Practice Address - Street 2:
Practice Address - City:MONTAGUE
Practice Address - State:CA
Practice Address - Zip Code:96064-9682
Practice Address - Country:US
Practice Address - Phone:530-340-1490
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-10-20
Last Update Date:2020-10-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPT20432225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist