Provider Demographics
NPI:1902233901
Name:WALLACE-DUCHARME, DEBORAH LYNN (LPT)
Entity Type:Individual
Prefix:
First Name:DEBORAH
Middle Name:LYNN
Last Name:WALLACE-DUCHARME
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 1:30 LAKE SHORE RD
Mailing Address - Street 2:
Mailing Address - City:LANSING
Mailing Address - State:NY
Mailing Address - Zip Code:14882-9029
Mailing Address - Country:US
Mailing Address - Phone:607-227-5335
Mailing Address - Fax:
Practice Address - Street 1:1001 W SENECA ST
Practice Address - Street 2:
Practice Address - City:ITHACA
Practice Address - State:NY
Practice Address - Zip Code:14850-3342
Practice Address - Country:US
Practice Address - Phone:607-277-8020
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-10-04
Last Update Date:2013-10-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY006493-1225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist