Provider Demographics
NPI:1801823836
Name:WALLACE, ROSEMARIE (MSED, ATC)
Entity type:Individual
Prefix:MISS
First Name:ROSEMARIE
Middle Name:
Last Name:WALLACE
Suffix:
Gender:F
Credentials:MSED, ATC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1152 CUSHENDALL TER
Mailing Address - Street 2:APT 104
Mailing Address - City:ROCK HILL
Mailing Address - State:SC
Mailing Address - Zip Code:29730-6096
Mailing Address - Country:US
Mailing Address - Phone:803-323-2129
Mailing Address - Fax:803-323-2111
Practice Address - Street 1:1152 CUSHENDALL TER
Practice Address - Street 2:APT 104
Practice Address - City:ROCK HILL
Practice Address - State:SC
Practice Address - Zip Code:29730-6096
Practice Address - Country:US
Practice Address - Phone:803-323-2129
Practice Address - Fax:803-323-2111
Is Sole Proprietor?:No
Enumeration Date:2006-06-26
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA2255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer