Provider Demographics
NPI:1790794113
Name:WALLMAN, MARY (PT)
Entity Type:Individual
Prefix:
First Name:MARY
Middle Name:
Last Name:WALLMAN
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:20347 TIMBERLAKE RD
Mailing Address - Street 2:STE B
Mailing Address - City:LYNCHBURG
Mailing Address - State:VA
Mailing Address - Zip Code:24502-7352
Mailing Address - Country:US
Mailing Address - Phone:434-845-9053
Mailing Address - Fax:
Practice Address - Street 1:44 CLIFTON ST
Practice Address - Street 2:
Practice Address - City:LYNCHBURG
Practice Address - State:VA
Practice Address - Zip Code:24501-1422
Practice Address - Country:US
Practice Address - Phone:434-528-1848
Practice Address - Fax:434-845-6820
Is Sole Proprietor?:No
Enumeration Date:2006-08-05
Last Update Date:2016-11-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA2305003165225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA010052319Medicaid
VA010052319Medicaid
VA650000366Medicare ID - Type Unspecified