Provider Demographics
NPI:1255351813
Name:WALLACE, SANDI H (PT)
Entity type:Individual
Prefix:MS
First Name:SANDI
Middle Name:H
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 1:59 A JAMES ST.
Mailing Address - Street 2:
Mailing Address - City:HOMER
Mailing Address - State:NY
Mailing Address - Zip Code:13077
Mailing Address - Country:US
Mailing Address - Phone:315-416-4327
Mailing Address - Fax:866-550-6451
Practice Address - Street 1:59 A JAMES ST.
Practice Address - Street 2:
Practice Address - City:HOMER
Practice Address - State:NY
Practice Address - Zip Code:13077
Practice Address - Country:US
Practice Address - Phone:315-416-4327
Practice Address - Fax:866-550-6451
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-19
Last Update Date:2008-10-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY017462-1225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY000158099OtherEXCELLUS
NY364724OtherMVP
NYP00162216OtherMEDICARE RAILROAD
NY02458611Medicaid
NY02458611Medicaid