Individual
MICHELLE WALLACE
Active
Sole proprietor
Yes
Provider details
NPI number
Gender
F
Credential
PT
Contact information
Practice address
75 NORMAN PL, TENAFLY, NJ 07670-2537
(732) 761-0088
Mailing address
75 NORMAN PL, TENAFLY, NJ 07670-2537
Taxonomy
Speciality
Code
Description
License number
State
2081P0010X
Pediatric Rehabilitation Medicine Physician
Primary
40QA00591600
NJ
Other
Enumeration date
07/19/2012
Last updated
07/19/2012
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