Provider Demographics
NPI:1417992538
Name:WALLACE, KATIE A (PT)
Entity Type:Individual
Prefix:
First Name:KATIE
Middle Name:A
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 1:5 MERCURY CIR
Mailing Address - Street 2:
Mailing Address - City:ANDOVER
Mailing Address - State:MA
Mailing Address - Zip Code:01810-2410
Mailing Address - Country:US
Mailing Address - Phone:603-818-9528
Mailing Address - Fax:978-740-4720
Practice Address - Street 1:1 ARROW DR
Practice Address - Street 2:
Practice Address - City:WOBURN
Practice Address - State:MA
Practice Address - Zip Code:01801-2039
Practice Address - Country:US
Practice Address - Phone:781-935-2655
Practice Address - Fax:781-935-9097
Is Sole Proprietor?:No
Enumeration Date:2006-06-20
Last Update Date:2022-09-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NH2972225100000X
MA16906225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NH08Y008383NH09OtherANTHEM
NHAA51239OtherHARVARD PILGRIM HEALTH
NH3779390OtherCIGNA
ME020481677Medicaid
NH101051400OtherUS DEPT OF LABOR
NH26206OtherCIGNA
NH1297438OtherAETNA
ME098440OtherANTHEN
NH30394394Medicaid
NH755459OtherTUFTS