| Doctor Name: | BRIAN R WALLY |
| NPI Number: | 1053760157 |
| Entity Type Code: | Individual (1) |
| Gender: | M |
| Credentials: | DPT |
| License Number: | PT4733 |
| Business Practice Address: | 94 Main St Gorham, ME - 040381340 |
| Business Phone Number: | 2078395860 |
| Business Fax Number: | 2078392499 |
| Mailing Address: | 185 Ocean St, SOUTH PORTLAND |
| State: | ME |
| Postal Code: | 041063600 |
| Phone Number: | 2077998226 |
| Fax Number: | 2077999340 |
| NPI Enumeration Date: | 06/09/2016 |
| NPI Last Update Date: | 06/09/2016 |
| Replacement NPI: | 0 |
| NPI Deactivation Date: | |
| NPI Reactivation Date: |
Taxonomy Information: | |
| Healthcare Provider Taxonomy: | 225100000X |
| License Number: | PT4733 |
| Healthcare Provider Taxonomy: (Secondary) | Y |
| State: | ME |
| Taxonomy Type: | Respiratory, Developmental, Rehabilitative and Restorative Service Providers |
| Taxonomy Classification: | Physical Therapist |
| Taxonomy Specialization: | |
| Taxonomy Definition: | (1) Physical therapists are health care professionals who evaluate and treat people with health problems resulting from injury or disease. PT |