Provider Demographics
NPI:1942858543
Name:WALLACE, CYDNEY T (DPT)
Entity Type:Individual
Prefix:
First Name:CYDNEY
Middle Name:T
Last Name:WALLACE
Suffix:
Gender:F
Credentials:DPT
Other - Prefix:
Other - First Name:CYDNEY
Other - Middle Name:T
Other - Last Name:SMITH
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:PO BOX 744113
Mailing Address - Street 2:
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30384-0492
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:410-535-9851
Practice Address - Street 1:5900 E VIRGINIA BEACH BLVD STE 21
Practice Address - Street 2:
Practice Address - City:NORFOLK
Practice Address - State:VA
Practice Address - Zip Code:23502-2499
Practice Address - Country:US
Practice Address - Phone:757-995-1903
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-08-28
Last Update Date:2024-03-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MD27626225100000X
VA2305216315225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist