Provider Demographics
NPI:1982346722
Name:WALLACE, IAN CARROLL (PT)
Entity Type:Individual
Prefix:
First Name:IAN
Middle Name:CARROLL
Last Name:WALLACE
Suffix:
Gender:M
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2314 WILLOW COVE DR
Mailing Address - Street 2:
Mailing Address - City:ROSHARON
Mailing Address - State:TX
Mailing Address - Zip Code:77583-3227
Mailing Address - Country:US
Mailing Address - Phone:832-483-4291
Mailing Address - Fax:
Practice Address - Street 1:10125 KATY FWY STE 100
Practice Address - Street 2:
Practice Address - City:HOUSTON
Practice Address - State:TX
Practice Address - Zip Code:77024-1287
Practice Address - Country:US
Practice Address - Phone:713-984-6270
Practice Address - Fax:713-242-3931
Is Sole Proprietor?:No
Enumeration Date:2022-04-12
Last Update Date:2022-04-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX1220166225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist