Provider Demographics
NPI:1902116122
Name:WALLACE, ANDREA (PT)
Entity type:Individual
Prefix:
First Name:ANDREA
Middle Name:
Last Name:WALLACE
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1231 PINE GROVE AVE
Mailing Address - Street 2:SUITE 1A
Mailing Address - City:PORT HURON
Mailing Address - State:MI
Mailing Address - Zip Code:48060-3500
Mailing Address - Country:US
Mailing Address - Phone:810-985-6300
Mailing Address - Fax:
Practice Address - Street 1:1231 PINE GROVE AVE
Practice Address - Street 2:SUITE 1A
Practice Address - City:PORT HURON
Practice Address - State:MI
Practice Address - Zip Code:48060-3500
Practice Address - Country:US
Practice Address - Phone:810-985-6300
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-10-21
Last Update Date:2010-10-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5501010425225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist