Provider Demographics
NPI:1386441822
Name:WALLACE, KATHLEEN MICHELLE
Entity type:Individual
Prefix:
First Name:KATHLEEN
Middle Name:MICHELLE
Last Name:WALLACE
Suffix:
Gender:
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:150 N BENNETT ST
Mailing Address - Street 2:
Mailing Address - City:SOUTHERN PINES
Mailing Address - State:NC
Mailing Address - Zip Code:28387-4809
Mailing Address - Country:US
Mailing Address - Phone:910-691-1669
Mailing Address - Fax:
Practice Address - Street 1:150 N BENNETT ST
Practice Address - Street 2:
Practice Address - City:SOUTHERN PINES
Practice Address - State:NC
Practice Address - Zip Code:28387-4809
Practice Address - Country:US
Practice Address - Phone:910-691-1669
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2025-03-03
Last Update Date:2025-03-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC15420225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist