Provider Demographics
NPI:1750639571
Name:WALLIN, BETHANY A (DPT)
Entity Type:Individual
Prefix:
First Name:BETHANY
Middle Name:A
Last Name:WALLIN
Suffix:
Gender:F
Credentials:DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:315 S SETH CHILD RD
Mailing Address - Street 2:
Mailing Address - City:MANHATTAN
Mailing Address - State:KS
Mailing Address - Zip Code:66502-3003
Mailing Address - Country:US
Mailing Address - Phone:785-776-3322
Mailing Address - Fax:
Practice Address - Street 1:315 S SETH CHILD RD
Practice Address - Street 2:
Practice Address - City:MANHATTAN
Practice Address - State:KS
Practice Address - Zip Code:66502-3003
Practice Address - Country:US
Practice Address - Phone:785-776-3322
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-08-28
Last Update Date:2012-08-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KS1104449225100000X
NE3031225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist