Provider Demographics
NPI:1245446723
Name:WALLACE, MARY FRANCES (LMT)
Entity type:Individual
Prefix:MS
First Name:MARY
Middle Name:FRANCES
Last Name:WALLACE
Suffix:
Gender:F
Credentials:LMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:970 NORWAY AVE
Mailing Address - Street 2:
Mailing Address - City:HUNTINGTON
Mailing Address - State:WV
Mailing Address - Zip Code:25705-3948
Mailing Address - Country:US
Mailing Address - Phone:304-412-3992
Mailing Address - Fax:
Practice Address - Street 1:3301 RIVER AVE
Practice Address - Street 2:
Practice Address - City:HUNTINGTON
Practice Address - State:WV
Practice Address - Zip Code:25705-2807
Practice Address - Country:US
Practice Address - Phone:304-412-3992
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-14
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV2006-2004225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist