=====================================================
General NPI Number Information
=====================================================
NPI Number | 1902233901
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | DEBORAH LYNN WALLACE-DUCHARME L.P.T.
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 10/04/2013
-----------------------------------------------------
Last Update Date | 10/04/2013
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1001 W SENECA ST
-----------------------------------------------------
City | ITHACA
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 14850-3342
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 607-277-8020
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 30 LAKE SHORE RD
-----------------------------------------------------
City | LANSING
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 14882-9029
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 607-227-5335
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 225100000X
-----------------------------------------------------
Taxonomy Name | Physical Therapist
-----------------------------------------------------
License Number | 006493-1
-----------------------------------------------------
License Number State | NY
-----------------------------------------------------