Provider Demographics
NPI:1831150705
Name:WALLACE, BETSY A (PT OCS)
Entity type:Individual
Prefix:
First Name:BETSY
Middle Name:A
Last Name:WALLACE
Suffix:
Gender:F
Credentials:PT OCS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:600 S ANDREASEN DR
Mailing Address - Street 2:STE C
Mailing Address - City:ESCONDIDO
Mailing Address - State:CA
Mailing Address - Zip Code:92029-1917
Mailing Address - Country:US
Mailing Address - Phone:760-591-7750
Mailing Address - Fax:760-294-9813
Practice Address - Street 1:3703 CAMINO DEL RIO S
Practice Address - Street 2:STE 100A
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92108-4031
Practice Address - Country:US
Practice Address - Phone:619-269-2336
Practice Address - Fax:619-269-7608
Is Sole Proprietor?:No
Enumeration Date:2006-03-30
Last Update Date:2010-03-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPT16506225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CACW038ZOtherMEDICARE
CACW038XOtherMEDICARE
CACW038YOtherMEDICARE
CACW038YOtherMEDICARE
CACW038ZOtherMEDICARE