Provider Demographics
NPI:1104372473
Name:WALLACH, DANIEL
Entity type:Individual
Prefix:
First Name:DANIEL
Middle Name:
Last Name:WALLACH
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:823 SE 36TH ST
Mailing Address - Street 2:
Mailing Address - City:BATTLE GROUND
Mailing Address - State:WA
Mailing Address - Zip Code:98604-3197
Mailing Address - Country:US
Mailing Address - Phone:541-373-7880
Mailing Address - Fax:
Practice Address - Street 1:2621 NE 134TH ST STE 140
Practice Address - Street 2:
Practice Address - City:VANCOUVER
Practice Address - State:WA
Practice Address - Zip Code:98686-3036
Practice Address - Country:US
Practice Address - Phone:360-504-0122
Practice Address - Fax:360-839-1354
Is Sole Proprietor?:No
Enumeration Date:2016-08-28
Last Update Date:2025-01-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
225200000X
OR9921225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant