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General NPI Number Information
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NPI Number | 1750788527
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Entity Type | Individual
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Provider Name | KOURTNEY WALLICK PT, DPT
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Gender | Female
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Dates
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Enumeration Date | 11/22/2014
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Last Update Date | 12/23/2021
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Provider Practice Location Address
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Address Line | 91 MAIN ST STE 122
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City | WARREN
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State | RI
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Zip | 02885-4437
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Country | US
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Telephone | 401-289-2999
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Fax |
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Provider Business Mailing Address
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Address Line | 4 RICHMOND SQ STE 200
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City | PROVIDENCE
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State | RI
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Zip | 02906-5117
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Country | US
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Telephone |
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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 |
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License Number State |
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Taxonomy #2
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Taxonomy Code | 225100000X
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Taxonomy Name | Physical Therapist
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License Number | PT02767
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License Number State | RI
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