Provider Demographics
NPI:1508880493
Name:WALLACE, WILLIAM C (PT)
Entity Type:Individual
Prefix:
First Name:WILLIAM
Middle Name:C
Last Name:WALLACE
Suffix:
Gender:M
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1113 N CASTLE HEIGHTS AVE
Mailing Address - Street 2:SUITE D
Mailing Address - City:LEBANON
Mailing Address - State:TN
Mailing Address - Zip Code:37087-5640
Mailing Address - Country:US
Mailing Address - Phone:615-965-9000
Mailing Address - Fax:615-965-9001
Practice Address - Street 1:1113 N CASTLE HEIGHTS AVE
Practice Address - Street 2:SUITE D
Practice Address - City:LEBANON
Practice Address - State:TN
Practice Address - Zip Code:37087-5640
Practice Address - Country:US
Practice Address - Phone:615-965-9000
Practice Address - Fax:615-965-9001
Is Sole Proprietor?:No
Enumeration Date:2006-07-26
Last Update Date:2013-06-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TNPT 4793225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN4793OtherPT LICENSE