| Doctor Name: | MR. BRIAN LESLIE WALLACE |
| NPI Number: | 1790888501 |
| Entity Type Code: | Individual (1) |
| Gender: | M |
| Credentials: | MS PT |
| License Number: | 10128 |
| Business Practice Address: | 901 Halstead Blvd Elizabeth City, NC - 279096920 |
| Business Phone Number: | 2523380137 |
| Business Fax Number: | |
| Mailing Address: | 1105 W Church St, ELIZABETH CITY |
| State: | NC |
| Postal Code: | 279094609 |
| Phone Number: | 2523385948 |
| Fax Number: | |
| NPI Enumeration Date: | 09/07/2006 |
| NPI Last Update Date: | 07/08/2007 |
| Replacement NPI: | 0 |
| NPI Deactivation Date: | |
| NPI Reactivation Date: |
Taxonomy Information: | |
| Healthcare Provider Taxonomy: | 225100000X |
| License Number: | 10128 |
| Healthcare Provider Taxonomy: (Secondary) | Y |
| State: | NC |
| 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 |