Provider Demographics
NPI:1184802787
Name:WALLACE, LINDA W (PT)
Entity type:Individual
Prefix:
First Name:LINDA
Middle Name:W
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 1:11740 COLUMBIA ST
Mailing Address - Street 2:
Mailing Address - City:BLAKELY
Mailing Address - State:GA
Mailing Address - Zip Code:39823-2574
Mailing Address - Country:US
Mailing Address - Phone:229-724-4269
Mailing Address - Fax:229-723-2354
Practice Address - Street 1:11740 COLUMBIA ST
Practice Address - Street 2:
Practice Address - City:BLAKELY
Practice Address - State:GA
Practice Address - Zip Code:39823-2574
Practice Address - Country:US
Practice Address - Phone:229-724-4269
Practice Address - Fax:229-723-2354
Is Sole Proprietor?:No
Enumeration Date:2008-02-06
Last Update Date:2015-06-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAPT0009259225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA688951544AMedicaid