Provider Demographics
NPI:1639254246
Name:WALLACE, KATHRYN SUSAN (DPT, ATS)
Entity Type:Individual
Prefix:MRS
First Name:KATHRYN
Middle Name:SUSAN
Last Name:WALLACE
Suffix:
Gender:F
Credentials:DPT, ATS
Other - Prefix:
Other - First Name:KATHRYN
Other - Middle Name:SUSAN
Other - Last Name:SCHULTZ
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:2373 DELO DR
Mailing Address - Street 2:
Mailing Address - City:GIBSONIA
Mailing Address - State:PA
Mailing Address - Zip Code:15044-9158
Mailing Address - Country:US
Mailing Address - Phone:724-713-1964
Mailing Address - Fax:
Practice Address - Street 1:2373 DELO DR
Practice Address - Street 2:
Practice Address - City:GIBSONIA
Practice Address - State:PA
Practice Address - Zip Code:15044-9158
Practice Address - Country:US
Practice Address - Phone:724-713-1964
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-25
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAPA016454225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist