Laurie Ann Wallace, MPT, ATC

Primary specialty

Physical TherapistTaxonomy code 225100000X

License

42268 Issued in CA

Practice address

130 Loma Vista Dr
Burlingame, CA 94010

Phone

(772) 321-4992

NPI assigned

May 1, 2007

Last updated

Feb 27, 2019By the provider in NPPES

Sex

Female

Sole proprietor

Yes

Registry information is reported by the provider to CMS and is not verified. About this source

Specialties & licenses 3

Addresses

Medicare fee-for-service enrollment

Not listed in the public Medicare enrollment file

Medicare enrollment (NPD)

Enrolled

State licenses

The complete NPPES record for this NPI in the NPI Registry API format.

{
    "created_epoch": "1177977600000",
    "enumeration_type": "NPI-1",
    "last_updated_epoch": "1551225600000",
    "number": "1770704306",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "130 LOMA VISTA DR",
            "city": "BURLINGAME",
            "state": "CA",
            "postal_code": "940106005",
            "telephone_number": "772-321-4992"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "130 LOMA VISTA DR",
            "city": "BURLINGAME",
            "state": "CA",
            "postal_code": "94010",
            "telephone_number": "772-321-4992"
        }
    ],
    "practiceLocations": [
        {
            "address_1": "438 Wisnom Ave",
            "address_purpose": "LOCATION",
            "city": "San Mateo",
            "state": "CA",
            "postal_code": "944012422",
            "country_code": "US",
            "telephone_number": "772-321-4992",
            "country_name": "United States",
            "address_type": "DOM"
        }
    ],
    "basic": {
        "last_name": "WALLACE",
        "first_name": "LAURIE",
        "middle_name": "ANN",
        "name_prefix": "Mrs.",
        "credential": "MPT, ATC",
        "sole_proprietor": "YES",
        "sex": "F",
        "enumeration_date": "2007-05-01",
        "last_updated": "2019-02-27",
        "status": "A"
    },
    "taxonomies": [
        {
            "code": "225100000X",
            "taxonomy_group": "",
            "desc": "Physical Therapist",
            "state": "FL",
            "license": "PT18527",
            "primary": false
        },
        {
            "code": "225100000X",
            "taxonomy_group": "",
            "desc": "Physical Therapist",
            "state": "CA",
            "license": "42268",
            "primary": true
        },
        {
            "code": "2255A2300X",
            "taxonomy_group": "",
            "desc": "Specialist/Technologist, Athletic Trainer",
            "state": "FL",
            "license": "AL617",
            "primary": false
        }
    ],
    "identifiers": [],
    "endpoints": [],
    "other_names": []
}

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• Physical Therapist in Burlingame, CA
• Providers in Burlingame, CA by specialty
• Physical Therapist in California

• NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Feb 27, 2019; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
• National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.

Verify at the official NPI Registry.