Provider Demographics
NPI:1558417436
Name:WALLACE, LAURA JEAN (LPTA)
Entity Type:Individual
Prefix:MRS
First Name:LAURA
Middle Name:JEAN
Last Name:WALLACE
Suffix:
Gender:F
Credentials:LPTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10596 CROW RD
Mailing Address - Street 2:
Mailing Address - City:LITCHFIELD
Mailing Address - State:OH
Mailing Address - Zip Code:44253-9537
Mailing Address - Country:US
Mailing Address - Phone:330-723-5765
Mailing Address - Fax:
Practice Address - Street 1:4691 WINDFALL RD
Practice Address - Street 2:
Practice Address - City:MEDINA
Practice Address - State:OH
Practice Address - Zip Code:44256-8705
Practice Address - Country:US
Practice Address - Phone:330-727-7751
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-01-25
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH02040225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant