Provider Demographics
NPI:1497263487
Name:WALLACE, EMMA MADISON LESTER (PT, DPT)
Entity Type:Individual
Prefix:
First Name:EMMA
Middle Name:MADISON LESTER
Last Name:WALLACE
Suffix:
Gender:F
Credentials:PT, DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:360 PEAK ONE DR
Mailing Address - Street 2:SUITE 190
Mailing Address - City:FRISCO
Mailing Address - State:CO
Mailing Address - Zip Code:80443
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:360 PEAK ONE DR
Practice Address - Street 2:SUITE 190
Practice Address - City:FRISCO
Practice Address - State:CO
Practice Address - Zip Code:80443
Practice Address - Country:US
Practice Address - Phone:970-668-0888
Practice Address - Fax:970-668-0227
Is Sole Proprietor?:No
Enumeration Date:2018-01-12
Last Update Date:2018-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO0015349225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist