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General NPI Number Information
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NPI Number | 1720883838
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Entity Type | Individual
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Provider Name | ASHLYN WALLACE
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Gender | Female
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Dates
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Enumeration Date | 02/14/2025
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Last Update Date | 02/14/2025
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Provider Practice Location Address
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Address Line | 200 PATEWOOD DR STE C250
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City | GREENVILLE
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State | SC
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Zip | 29615-3593
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Country | US
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Telephone | 864-780-4793
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Fax |
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Provider Business Mailing Address
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Address Line | 2001 BUTTERFIELD RD STE 1600
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City | DOWNERS GROVE
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State | IL
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Zip | 60515-1211
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Country | US
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Telephone | 866-370-8206
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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 | 225100000X
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Taxonomy Name | Physical Therapist
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License Number | 12701
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License Number State | SC
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