Provider Demographics
NPI:1396761995
Name:WALLACE, MAUREEN V (MPT)
Entity type:Individual
Prefix:
First Name:MAUREEN
Middle Name:V
Last Name:WALLACE
Suffix:
Gender:F
Credentials:MPT
Other - Prefix:
Other - First Name:MAUREEN
Other - Middle Name:TAMARA
Other - Last Name:VAN HORN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MPT
Mailing Address - Street 1:4739 MEADOW LANE
Mailing Address - Street 2:
Mailing Address - City:BOZEMAN
Mailing Address - State:MT
Mailing Address - Zip Code:59715
Mailing Address - Country:US
Mailing Address - Phone:406-586-2772
Mailing Address - Fax:406-586-2644
Practice Address - Street 1:2430 N. 7TH
Practice Address - Street 2:UNIT 2
Practice Address - City:BOZEMAN
Practice Address - State:MT
Practice Address - Zip Code:59715
Practice Address - Country:US
Practice Address - Phone:406-586-2772
Practice Address - Fax:406-586-2644
Is Sole Proprietor?:No
Enumeration Date:2006-07-15
Last Update Date:2009-11-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MT1931PT225100000X
MT1931225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MT000061621OtherBCBS MT
MT3402057Medicaid
MT3402057Medicaid