Individual
CASEY L. WALLACE
Active
Sole proprietor
No
Provider details
NPI number
Gender
F
Credential
PT, DPT
Contact information
Practice address
984B LASKIN RD, VIRGINIA BEACH, VA 23451-3905
(757) 395-6900
(757) 425-7180
Mailing address
984B LASKIN RD, VIRGINIA BEACH, VA 23451-3905
(757) 395-6900
(757) 425-7180
Taxonomy
Speciality
Code
Description
License number
State
225100000X
Physical Therapist
Primary
2305207461
VA
Other
Other identifiers
Code
Description
Identifier
Issuer
State
05
—
1134474323
—
VA
01
—
C05954
GROUP MEDICARE PTAN
VA
Enumeration date
07/13/2012
Last updated
03/22/2021
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