Provider Demographics
NPI:1720269335
Name:WALLACE, MARIESOL FIGUEROA (PT)
Entity Type:Individual
Prefix:MRS
First Name:MARIESOL
Middle Name:FIGUEROA
Last Name:WALLACE
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1615 HORSEDRAWN CT
Mailing Address - Street 2:
Mailing Address - City:SEVERN
Mailing Address - State:MD
Mailing Address - Zip Code:21144-6808
Mailing Address - Country:US
Mailing Address - Phone:443-688-6220
Mailing Address - Fax:
Practice Address - Street 1:1615 HORSEDRAWN CT
Practice Address - Street 2:
Practice Address - City:SEVERN
Practice Address - State:MD
Practice Address - Zip Code:21144-6808
Practice Address - Country:US
Practice Address - Phone:443-688-6220
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-11-26
Last Update Date:2007-11-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MD20334225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist