Provider Demographics
NPI:1386601516
Name:WALLACE, SALLIE CT (ATC/L)
Entity type:Individual
Prefix:MS
First Name:SALLIE
Middle Name:CT
Last Name:WALLACE
Suffix:
Gender:F
Credentials:ATC/L
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
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Other - Credentials:
Mailing Address - Street 1:417 S 4TH ST
Mailing Address - Street 2:
Mailing Address - City:MURFREESBORO
Mailing Address - State:NC
Mailing Address - Zip Code:27855-2003
Mailing Address - Country:US
Mailing Address - Phone:252-398-6291
Mailing Address - Fax:252-398-1390
Practice Address - Street 1:200 JONES DR
Practice Address - Street 2:
Practice Address - City:MURFREESBORO
Practice Address - State:NC
Practice Address - Zip Code:27855-1844
Practice Address - Country:US
Practice Address - Phone:252-398-6291
Practice Address - Fax:252-398-1390
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-05-01
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC10732255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer