Provider Demographics
NPI:1417183476
Name:WALLACE, ERIC T (DPT)
Entity Type:Individual
Prefix:DR
First Name:ERIC
Middle Name:T
Last Name:WALLACE
Suffix:
Gender:M
Credentials:DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:W5361 COUNTY ROAD KK STE E
Mailing Address - Street 2:
Mailing Address - City:APPLETON
Mailing Address - State:WI
Mailing Address - Zip Code:54915-7271
Mailing Address - Country:US
Mailing Address - Phone:920-540-2344
Mailing Address - Fax:920-779-1460
Practice Address - Street 1:W5361 COUNTY ROAD KK STE E
Practice Address - Street 2:
Practice Address - City:APPLETON
Practice Address - State:WI
Practice Address - Zip Code:54915-7271
Practice Address - Country:US
Practice Address - Phone:920-540-2344
Practice Address - Fax:920-779-1460
Is Sole Proprietor?:Yes
Enumeration Date:2009-06-04
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI11251-242251X0800X
WI11251225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
No2251X0800XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistOrthopedic