Provider Demographics
NPI:1962776948
Name:WALLACE, MANDY L (MSRPT)
Entity type:Individual
Prefix:MS
First Name:MANDY
Middle Name:L
Last Name:WALLACE
Suffix:
Gender:F
Credentials:MSRPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1465 NORWOOD RD
Mailing Address - Street 2:
Mailing Address - City:OLANTA
Mailing Address - State:SC
Mailing Address - Zip Code:29114-9533
Mailing Address - Country:US
Mailing Address - Phone:843-687-2068
Mailing Address - Fax:
Practice Address - Street 1:121 E CEDAR ST
Practice Address - Street 2:
Practice Address - City:FLORENCE
Practice Address - State:SC
Practice Address - Zip Code:29506-2576
Practice Address - Country:US
Practice Address - Phone:843-661-3426
Practice Address - Fax:843-661-3599
Is Sole Proprietor?:No
Enumeration Date:2012-03-08
Last Update Date:2012-03-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC4051225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist