Provider Demographics
NPI:1356558324
Name:WALLIS, JUDY LYNN (PTA)
Entity type:Individual
Prefix:MRS
First Name:JUDY
Middle Name:LYNN
Last Name:WALLIS
Suffix:
Gender:F
Credentials:PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8572 MCARTHUR AVE NE
Mailing Address - Street 2:
Mailing Address - City:GREENVILLE
Mailing Address - State:MI
Mailing Address - Zip Code:48838-8372
Mailing Address - Country:US
Mailing Address - Phone:616-481-4235
Mailing Address - Fax:
Practice Address - Street 1:MARYWOOD HEALTH CENTER
Practice Address - Street 2:111 LAKESIDE DRIVE NE
Practice Address - City:GRAND RAPIDS
Practice Address - State:MI
Practice Address - Zip Code:49503
Practice Address - Country:US
Practice Address - Phone:616-453-7715
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-17
Last Update Date:2018-12-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5502000688225200000X
225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant