Provider Demographics
NPI:1578711933
Name:WALL, RUTH (PTA)
Entity Type:Individual
Prefix:
First Name:RUTH
Middle Name:
Last Name:WALL
Suffix:
Gender:F
Credentials:PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:374 CHESTNUT RIDGE RD
Mailing Address - Street 2:
Mailing Address - City:WALLAND
Mailing Address - State:TN
Mailing Address - Zip Code:37886-2839
Mailing Address - Country:US
Mailing Address - Phone:865-681-4256
Mailing Address - Fax:
Practice Address - Street 1:3300 N BROADWAY ST
Practice Address - Street 2:
Practice Address - City:KNOXVILLE
Practice Address - State:TN
Practice Address - Zip Code:37917-2733
Practice Address - Country:US
Practice Address - Phone:865-689-2052
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-08-28
Last Update Date:2008-08-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TNPTA2299225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant