Individual
MICHELL WALLACE
Active
Sole proprietor
No
Provider details
NPI number
Gender
F
Credential
PTA
Contact information
Practice address
6448 MAIN ST, TRUMBULL, CT 06611-2075
(203) 268-6204
Mailing address
2810 OLD TOWN RD, BRIDGEPORT, CT 06606-1243
(203) 502-1502
Taxonomy
Speciality
Code
Description
License number
State
225200000X
Physical Therapy Assistant
Primary
000988
CT
Other
Enumeration date
11/24/2012
Last updated
11/24/2012
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