Provider Demographics
NPI:1538323720
Name:WALLACE, LILLIAN STENSON (PT)
Entity Type:Individual
Prefix:MRS
First Name:LILLIAN
Middle Name:STENSON
Last Name:WALLACE
Suffix:
Gender:F
Credentials:PT
Other - Prefix:MISS
Other - First Name:LILLION
Other - Middle Name:MARIA
Other - Last Name:STENSON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PT
Mailing Address - Street 1:105 KIMBERWICK TRL
Mailing Address - Street 2:
Mailing Address - City:NEWNAN
Mailing Address - State:GA
Mailing Address - Zip Code:30263-7110
Mailing Address - Country:US
Mailing Address - Phone:404-314-1933
Mailing Address - Fax:770-251-9817
Practice Address - Street 1:105 KIMBERWICK TRL
Practice Address - Street 2:
Practice Address - City:NEWNAN
Practice Address - State:GA
Practice Address - Zip Code:30263-7110
Practice Address - Country:US
Practice Address - Phone:404-314-1933
Practice Address - Fax:770-251-9817
Is Sole Proprietor?:Yes
Enumeration Date:2008-07-16
Last Update Date:2008-07-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAPT004075225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA65BBBPLMedicare UPIN