Provider Demographics
NPI:1053419671
Name:WALLACE, KATHY WRIGHT (LPT)
Entity type:Individual
Prefix:MRS
First Name:KATHY
Middle Name:WRIGHT
Last Name:WALLACE
Suffix:
Gender:F
Credentials:LPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1352 MATTHEWS TOWNSHIP PARKWAY
Mailing Address - Street 2:UNIT 102
Mailing Address - City:MATTHEWS
Mailing Address - State:NC
Mailing Address - Zip Code:28105
Mailing Address - Country:US
Mailing Address - Phone:704-847-6351
Mailing Address - Fax:704-849-2826
Practice Address - Street 1:1352 MATTHEWS TOWNSHIP PARKWAY
Practice Address - Street 2:UNIT 102
Practice Address - City:MATTHEWS
Practice Address - State:NC
Practice Address - Zip Code:28105
Practice Address - Country:US
Practice Address - Phone:704-847-6351
Practice Address - Fax:704-849-2826
Is Sole Proprietor?:No
Enumeration Date:2006-09-20
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCLPT1370225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist