Provider Demographics
NPI:1790888501
Name:WALLACE, BRIAN LESLIE (MS PT)
Entity Type:Individual
Prefix:MR
First Name:BRIAN
Middle Name:LESLIE
Last Name:WALLACE
Suffix:
Gender:M
Credentials:MS PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1105 W CHURCH ST
Mailing Address - Street 2:
Mailing Address - City:ELIZABETH CITY
Mailing Address - State:NC
Mailing Address - Zip Code:27909-4609
Mailing Address - Country:US
Mailing Address - Phone:252-338-5948
Mailing Address - Fax:
Practice Address - Street 1:901 HALSTEAD BLVD
Practice Address - Street 2:
Practice Address - City:ELIZABETH CITY
Practice Address - State:NC
Practice Address - Zip Code:27909-6920
Practice Address - Country:US
Practice Address - Phone:252-338-0137
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-09-07
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC10128225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist