MEDICARE: JOANN RAE WALLACE LMT

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	225700000X	Massage Therapist	MT11445	SD

General Provider Information

NPI Number	:	1912845132
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	JOANN RAE WALLACE LMT

Provider Business Mailing Address
First Line	:	805 HARVARD ST APT A
Second Line	:
City	:	SPEARFISH
State	:	SD
Zip	:	57783-1898
Country	:	US
Telephone Number	:	605-641-4674
Fax Number	:

Provider Business Practice Location Address
First Line	:	529 N MAIN ST
Second Line	:
City	:	SPEARFISH
State	:	SD
Zip	:	57783-2345
Country	:	US
Telephone Number	:	605-641-4674
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	03/23/2026
Last Update Date	:	03/23/2026

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