Healthcare Provider Details

I. General information

NPI: 1326166315
Provider Name (Legal Business Name): ANDREA YVONNE WALLACE LPTA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/27/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3 MERIT DR
RICHMOND HEIGHTS OH
44143-1457
US

IV. Provider business mailing address

1240 LEEWARD LN APT B
WILLOUGHBY OH
44094-7008
US

V. Phone/Fax

Practice location:
  • Phone: 216-261-9600
  • Fax:
Mailing address:
  • Phone: 440-476-7262
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225200000X
TaxonomyPhysical Therapy Assistant
License Number3101
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: