Provider Demographics
NPI:1750788527
Name:WALLICK, KOURTNEY (PT, DPT)
Entity type:Individual
Prefix:
First Name:KOURTNEY
Middle Name:
Last Name:WALLICK
Suffix:
Gender:F
Credentials:PT, DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4 RICHMOND SQ STE 200
Mailing Address - Street 2:
Mailing Address - City:PROVIDENCE
Mailing Address - State:RI
Mailing Address - Zip Code:02906-5117
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:91 MAIN ST STE 122
Practice Address - Street 2:
Practice Address - City:WARREN
Practice Address - State:RI
Practice Address - Zip Code:02885-4437
Practice Address - Country:US
Practice Address - Phone:401-289-2999
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-11-22
Last Update Date:2021-12-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
225100000X
RIPT02767225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist