Healthcare Provider Details

I. General information

NPI: 1285896860
Provider Name (Legal Business Name): WALLACE THERAPY INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/25/2008
Last Update Date: 06/25/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9912 SPRING RIDGE DR
LOUISVILLE KY
40223-2877
US

IV. Provider business mailing address

9912 SPRING RIDGE DR
LOUISVILLE KY
40223-2877
US

V. Phone/Fax

Practice location:
  • Phone: 502-442-4005
  • Fax: 502-742-4469
Mailing address:
  • Phone: 502-442-4005
  • Fax: 502-742-4469

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code252Y00000X
TaxonomyEarly Intervention Provider Agency
License Number
License Number StateKY

VIII. Authorized Official

Name: SHERRELL K BAILEY
Title or Position: PRESIDENT
Credential: MS CCC/SLP
Phone: 502-442-4005