Provider Demographics
NPI:1801975255
Name:WALLACE, LAURRI (PT)
Entity type:Individual
Prefix:
First Name:LAURRI
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 1:1004 BANKHEAD HWY
Mailing Address - Street 2:BLDG A, STE 5
Mailing Address - City:CARROLLTON
Mailing Address - State:GA
Mailing Address - Zip Code:30117-1852
Mailing Address - Country:US
Mailing Address - Phone:770-834-5609
Mailing Address - Fax:267-321-1352
Practice Address - Street 1:1004 BANKHEAD HWY
Practice Address - Street 2:BLDG A, STE 5
Practice Address - City:CARROLLTON
Practice Address - State:GA
Practice Address - Zip Code:30117-1852
Practice Address - Country:US
Practice Address - Phone:770-834-5609
Practice Address - Fax:267-321-1352
Is Sole Proprietor?:No
Enumeration Date:2006-11-06
Last Update Date:2010-05-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAPT006593225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
GAPT006593OtherSTATE LISC NUMBER