Provider Demographics
NPI:1255122339
Name:WALLACE, ELIZABETH (LMT)
Entity type:Individual
Prefix:
First Name:ELIZABETH
Middle Name:
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 1:8645 ACONITE DR
Mailing Address - Street 2:
Mailing Address - City:BLACKLICK
Mailing Address - State:OH
Mailing Address - Zip Code:43004-7155
Mailing Address - Country:US
Mailing Address - Phone:614-905-9199
Mailing Address - Fax:
Practice Address - Street 1:7323 E MAIN ST
Practice Address - Street 2:
Practice Address - City:REYNOLDSBURG
Practice Address - State:OH
Practice Address - Zip Code:43068-2159
Practice Address - Country:US
Practice Address - Phone:614-905-9199
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2025-05-16
Last Update Date:2025-05-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH33.025883225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist