Provider Demographics
NPI:1356686877
Name:WALLACE, JAMES STEVEN (PTA)
Entity Type:Individual
Prefix:MR
First Name:JAMES
Middle Name:STEVEN
Last Name:WALLACE
Suffix:
Gender:M
Credentials:PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:449 MAIN ST APT 131
Mailing Address - Street 2:
Mailing Address - City:ANDERSON
Mailing Address - State:IN
Mailing Address - Zip Code:46016-1186
Mailing Address - Country:US
Mailing Address - Phone:765-683-0633
Mailing Address - Fax:765-683-0603
Practice Address - Street 1:449 MAIN ST APT 131
Practice Address - Street 2:
Practice Address - City:ANDERSON
Practice Address - State:IN
Practice Address - Zip Code:46016-1186
Practice Address - Country:US
Practice Address - Phone:765-683-0633
Practice Address - Fax:765-683-0603
Is Sole Proprietor?:No
Enumeration Date:2012-12-10
Last Update Date:2012-12-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN06004510A225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant