Provider Demographics
NPI:1770099244
Name:WALLACE, DEVON (DPT)
Entity type:Individual
Prefix:
First Name:DEVON
Middle Name:
Last Name:WALLACE
Suffix:
Gender:F
Credentials:DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1808 PLAZA DR
Mailing Address - Street 2:
Mailing Address - City:WINCHESTER
Mailing Address - State:VA
Mailing Address - Zip Code:22601-6365
Mailing Address - Country:US
Mailing Address - Phone:540-665-2750
Mailing Address - Fax:540-665-2749
Practice Address - Street 1:101 W 14TH ST
Practice Address - Street 2:
Practice Address - City:FRONT ROYAL
Practice Address - State:VA
Practice Address - Zip Code:22630-3607
Practice Address - Country:US
Practice Address - Phone:540-636-3500
Practice Address - Fax:540-636-3502
Is Sole Proprietor?:Yes
Enumeration Date:2017-12-20
Last Update Date:2018-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA2305211669225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Single Specialty