Provider Demographics
NPI:1952787533
Name:WALLACE, KENNETH (PTA)
Entity Type:Individual
Prefix:
First Name:KENNETH
Middle Name:
Last Name:WALLACE
Suffix:
Gender:M
Credentials:PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:170 COREY RD
Mailing Address - Street 2:BRIGHTON HOUSE REHABILITATION AND NURSING CENTER
Mailing Address - City:BRIGHTON
Mailing Address - State:MA
Mailing Address - Zip Code:02135
Mailing Address - Country:US
Mailing Address - Phone:617-731-0515
Mailing Address - Fax:
Practice Address - Street 1:170 COREY RD
Practice Address - Street 2:BRIGHTON HOUSE REHABILITATION AND NURSING CENTER
Practice Address - City:BRIGHTON
Practice Address - State:MA
Practice Address - Zip Code:02135
Practice Address - Country:US
Practice Address - Phone:617-731-0515
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-08-05
Last Update Date:2015-08-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA8869225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant