Provider Demographics
NPI:1194407668
Name:WALLACE, SERENA A (DPT)
Entity type:Individual
Prefix:
First Name:SERENA
Middle Name:A
Last Name:WALLACE
Suffix:
Gender:F
Credentials:DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
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Other - Credentials:
Mailing Address - Street 1:206 W OLIVE AVE APT 3
Mailing Address - Street 2:
Mailing Address - City:REDLANDS
Mailing Address - State:CA
Mailing Address - Zip Code:92373-8810
Mailing Address - Country:US
Mailing Address - Phone:206-412-8460
Mailing Address - Fax:
Practice Address - Street 1:275 W HOSPITALITY LN STE 100
Practice Address - Street 2:
Practice Address - City:SAN BERNARDINO
Practice Address - State:CA
Practice Address - Zip Code:92408-3238
Practice Address - Country:US
Practice Address - Phone:909-567-2221
Practice Address - Fax:909-763-3216
Is Sole Proprietor?:Yes
Enumeration Date:2023-08-03
Last Update Date:2024-08-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAPT61456638225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist