Provider Demographics
NPI:1285877217
Name:WALLACE, COURTNEY BROOKE (PT)
Entity type:Individual
Prefix:
First Name:COURTNEY
Middle Name:BROOKE
Last Name:WALLACE
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9802 CARVEL CT
Mailing Address - Street 2:
Mailing Address - City:RALEIGH
Mailing Address - State:NC
Mailing Address - Zip Code:27613-5754
Mailing Address - Country:US
Mailing Address - Phone:984-200-2415
Mailing Address - Fax:
Practice Address - Street 1:3601 WINDEMERE PL
Practice Address - Street 2:
Practice Address - City:RALEIGH
Practice Address - State:NC
Practice Address - Zip Code:27604-5961
Practice Address - Country:US
Practice Address - Phone:919-601-0149
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2009-04-06
Last Update Date:2021-01-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC8974171W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171W00000XOther Service ProvidersContractor