Provider Demographics
NPI:1518153295
Name:WALLACE, SANDRA EUGENIA (MASSAGE THERAPIST)
Entity Type:Individual
Prefix:
First Name:SANDRA
Middle Name:EUGENIA
Last Name:WALLACE
Suffix:
Gender:F
Credentials:MASSAGE THERAPIST
Other - Prefix:
Other - First Name:SANDRA
Other - Middle Name:EUGENIA
Other - Last Name:WALLACE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:ASSOCIATES DEGREE
Mailing Address - Street 1:3627 ACORNRUN LN
Mailing Address - Street 2:
Mailing Address - City:SPRING
Mailing Address - State:TX
Mailing Address - Zip Code:77389-4721
Mailing Address - Country:US
Mailing Address - Phone:281-651-7716
Mailing Address - Fax:
Practice Address - Street 1:3627 ACORNRUN LN
Practice Address - Street 2:
Practice Address - City:SPRING
Practice Address - State:TX
Practice Address - Zip Code:77389-4721
Practice Address - Country:US
Practice Address - Phone:281-651-7716
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-09-17
Last Update Date:2007-09-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX016400225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist