Provider Demographics
NPI:1457899965
Name:WALLACE, TANYA L (LMT)
Entity type:Individual
Prefix:
First Name:TANYA
Middle Name:L
Last Name:WALLACE
Suffix:
Gender:F
Credentials:LMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:901 CHESWOLD CT
Mailing Address - Street 2:
Mailing Address - City:BEL AIR
Mailing Address - State:MD
Mailing Address - Zip Code:21014-5461
Mailing Address - Country:US
Mailing Address - Phone:410-913-2752
Mailing Address - Fax:
Practice Address - Street 1:452 CONGRESS AVE
Practice Address - Street 2:
Practice Address - City:HAVRE DE GRACE
Practice Address - State:MD
Practice Address - Zip Code:21078-3031
Practice Address - Country:US
Practice Address - Phone:410-913-2752
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-02-03
Last Update Date:2017-02-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDM04748225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist