Provider Demographics
NPI:1356921118
Name:WALLACE, DOUGLAS
Entity type:Individual
Prefix:
First Name:DOUGLAS
Middle Name:
Last Name:WALLACE
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:36 HUDSON PL
Mailing Address - Street 2:
Mailing Address - City:WEEHAWKEN
Mailing Address - State:NJ
Mailing Address - Zip Code:07086-7013
Mailing Address - Country:US
Mailing Address - Phone:201-522-6474
Mailing Address - Fax:
Practice Address - Street 1:36 HUDSON PL
Practice Address - Street 2:
Practice Address - City:WEEHAWKEN
Practice Address - State:NJ
Practice Address - Zip Code:07086-7013
Practice Address - Country:US
Practice Address - Phone:201-522-6474
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-04-14
Last Update Date:2021-04-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ40QA00655300225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist