Healthcare Provider Details

I. General information

NPI: 1083556591
Provider Name (Legal Business Name): GODIZA MARIE WALLACE
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/06/2026
Last Update Date: 04/20/2026
Certification Date: 04/20/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5425 WISCONSIN AVE STE 600
CHEVY CHASE MD
20815-3588
US

IV. Provider business mailing address

5425 WISCONSIN AVE STE 600
CHEVY CHASE MD
20815-3588
US

V. Phone/Fax

Practice location:
  • Phone: 866-525-3175
  • Fax:
Mailing address:
  • Phone: 866-525-3175
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number24366
License Number StateMD

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: