Provider Demographics
NPI:1518252618
Name:WALLACE, EMILY PAIGE (PT, DPT)
Entity type:Individual
Prefix:
First Name:EMILY
Middle Name:PAIGE
Last Name:WALLACE
Suffix:
Gender:F
Credentials:PT, DPT
Other - Prefix:
Other - First Name:EMILY
Other - Middle Name:WALLACE
Other - Last Name:HYMEL
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PT, DPT
Mailing Address - Street 1:7530 HIGHWAY 44 STE 108
Mailing Address - Street 2:
Mailing Address - City:GONZALES
Mailing Address - State:LA
Mailing Address - Zip Code:70737-8137
Mailing Address - Country:US
Mailing Address - Phone:225-258-9480
Mailing Address - Fax:
Practice Address - Street 1:7530 HIGHWAY 44 STE 108
Practice Address - Street 2:
Practice Address - City:GONZALES
Practice Address - State:LA
Practice Address - Zip Code:70737-8137
Practice Address - Country:US
Practice Address - Phone:225-258-9480
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-06-16
Last Update Date:2024-10-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA08092225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist