Provider Demographics
NPI:1538441241
Name:WALLACE, TRACY CLARK (PT)
Entity type:Individual
Prefix:MRS
First Name:TRACY
Middle Name:CLARK
Last Name:WALLACE
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
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Other - Credentials:
Mailing Address - Street 1:6600 PEACHTREE DUNWOODY RD NE
Mailing Address - Street 2:BLDG 400 STE 125
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30328-6773
Mailing Address - Country:US
Mailing Address - Phone:770-225-8421
Mailing Address - Fax:866-587-9993
Practice Address - Street 1:6600 PEACHTREE DUNWOODY RD NE
Practice Address - Street 2:BLDG 400 STE 125
Practice Address - City:ATLANTA
Practice Address - State:GA
Practice Address - Zip Code:30328-6773
Practice Address - Country:US
Practice Address - Phone:770-225-8421
Practice Address - Fax:866-587-9993
Is Sole Proprietor?:No
Enumeration Date:2011-09-20
Last Update Date:2011-09-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA6657225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist