Provider Demographics
NPI:1518788728
Name:WALLACE, CAROLYN ANN (PTA)
Entity type:Individual
Prefix:MRS
First Name:CAROLYN
Middle Name:ANN
Last Name:WALLACE
Suffix:
Gender:F
Credentials:PTA
Other - Prefix:MISS
Other - First Name:CAROLYN
Other - Middle Name:ANN
Other - Last Name:GODWIN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:177 ROGGERO RD APT 10
Mailing Address - Street 2:
Mailing Address - City:TONTITOWN
Mailing Address - State:AR
Mailing Address - Zip Code:72762-4520
Mailing Address - Country:US
Mailing Address - Phone:580-278-1104
Mailing Address - Fax:
Practice Address - Street 1:2070 MCKENZIE RD STE C
Practice Address - Street 2:
Practice Address - City:SPRINGDALE
Practice Address - State:AR
Practice Address - Zip Code:72762-0870
Practice Address - Country:US
Practice Address - Phone:479-750-7778
Practice Address - Fax:479-750-7708
Is Sole Proprietor?:Yes
Enumeration Date:2024-10-21
Last Update Date:2024-10-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AR4984225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy AssistantGroup - Single Specialty