Provider Demographics
NPI:1942464219
Name:WALLACE, BETHANN (PT)
Entity Type:Individual
Prefix:MRS
First Name:BETHANN
Middle Name:
Last Name:WALLACE
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 1:1416 CHURCHVILLE AVE
Mailing Address - Street 2:SUITE A
Mailing Address - City:STAUNTON
Mailing Address - State:VA
Mailing Address - Zip Code:24401
Mailing Address - Country:US
Mailing Address - Phone:540-213-0345
Mailing Address - Fax:
Practice Address - Street 1:1416 CHURCHVILLE AVE
Practice Address - Street 2:SUITE A
Practice Address - City:STAUNTON
Practice Address - State:VA
Practice Address - Zip Code:24401-1718
Practice Address - Country:US
Practice Address - Phone:540-213-0345
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-07-15
Last Update Date:2008-07-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA2305005759225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist