Provider Demographics
NPI:1790456614
Name:WALLACE, KASSY ARLENE (PT, DPT)
Entity Type:Individual
Prefix:
First Name:KASSY
Middle Name:ARLENE
Last Name:WALLACE
Suffix:
Gender:F
Credentials:PT, DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8872 PROFESSIONAL DR STE C
Mailing Address - Street 2:
Mailing Address - City:CADILLAC
Mailing Address - State:MI
Mailing Address - Zip Code:49601-8482
Mailing Address - Country:US
Mailing Address - Phone:231-876-0010
Mailing Address - Fax:231-876-0241
Practice Address - Street 1:8872 PROFESSIONAL DR STE C
Practice Address - Street 2:
Practice Address - City:CADILLAC
Practice Address - State:MI
Practice Address - Zip Code:49601-8482
Practice Address - Country:US
Practice Address - Phone:231-876-0010
Practice Address - Fax:231-876-0241
Is Sole Proprietor?:No
Enumeration Date:2021-09-21
Last Update Date:2022-08-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
MI55013017782251X0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2251X0800XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistOrthopedic
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program