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General NPI Number Information
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NPI Number | 1255122339
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Entity Type | Individual
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Provider Name | ELIZABETH WALLACE LMT
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Gender | Female
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Dates
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Enumeration Date | 05/16/2025
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Last Update Date | 05/16/2025
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Provider Practice Location Address
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Address Line | 7323 E MAIN ST
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City | REYNOLDSBURG
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State | OH
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Zip | 43068-2159
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Country | US
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Telephone | 614-905-9199
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Fax |
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Provider Business Mailing Address
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Address Line | 8645 ACONITE DR
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City | BLACKLICK
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State | OH
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Zip | 43004-7155
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Country | US
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Telephone | 614-905-9199
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 225700000X
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Taxonomy Name | Massage Therapist
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License Number | 33.025883
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License Number State | OH
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