Provider Demographics
NPI:1285896860
Name:WALLACE THERAPY INC
Entity type:Organization
Organization Name:WALLACE THERAPY INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:SHERRELL
Authorized Official - Middle Name:K
Authorized Official - Last Name:BAILEY
Authorized Official - Suffix:
Authorized Official - Credentials:MS CCC/SLP
Authorized Official - Phone:502-442-4005
Mailing Address - Street 1:9912 SPRING RIDGE DR
Mailing Address - Street 2:
Mailing Address - City:LOUISVILLE
Mailing Address - State:KY
Mailing Address - Zip Code:40223-2877
Mailing Address - Country:US
Mailing Address - Phone:502-442-4005
Mailing Address - Fax:502-742-4469
Practice Address - Street 1:9912 SPRING RIDGE DR
Practice Address - Street 2:
Practice Address - City:LOUISVILLE
Practice Address - State:KY
Practice Address - Zip Code:40223-2877
Practice Address - Country:US
Practice Address - Phone:502-442-4005
Practice Address - Fax:502-742-4469
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-06-25
Last Update Date:2008-06-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY252Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes252Y00000XAgenciesEarly Intervention Provider Agency