Healthcare Provider Details

I. General information

NPI: 1073671319
Provider Name (Legal Business Name): MARSHA A WALLACE PT
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/05/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

111 CLARA BARTON ST
DANSVILLE NY
14437-9503
US

IV. Provider business mailing address

10218 COUNTY ROUTE 92
WAYLAND NY
14572-9418
US

V. Phone/Fax

Practice location:
  • Phone: 585-335-4239
  • Fax: 585-335-4295
Mailing address:
  • Phone: 585-728-2079
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number4861
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: