Active NPI
Kenneth Wallace, PTA
- Physical Therapy Assistant
- Brighton, MA
National Provider Identifier
1952787533
On this page
Key facts
NPPES NPI Registry- Primary specialty
- Physical Therapy Assistant
- License
- 8869
- Practice address
- 170 Corey Rd
Brighton House Rehabilitation and Nursing Center
Brighton, MA 02135 - Phone
- (617) 731-0515
- NPI assigned
- Aug 5, 2015
- Last updated
- Aug 5, 2015
- Sex
- Male
- Sole proprietor
- No
NPPES NPI Registry
Registry information is reported by the provider to CMS and is not verified. About this source
Specialties & licenses 1
| Specialty (taxonomy) | Code | License | State | Primary |
|---|---|---|---|---|
| Physical Therapy Assistant | 225200000X | 8869 | MA | Primary |
Addresses
Primary practice location
170 Corey Rd
Brighton House Rehabilitation and Nursing Center
Brighton, MA 02135
Mailing address
170 Corey Rd
Brighton House Rehabilitation and Nursing Center
Brighton, MA 02135
Phone (617) 731-0515
Medicare participation
Medicare enrollment files- Medicare fee-for-service enrollment
- Not listed in the public Medicare enrollment file
National Provider Directory
National Provider Directory- Medicare enrollment (NPD)
- Not enrolled
State licenses
| License | State | Type | Specialty |
|---|---|---|---|
| 8869 | MA | MD | Occupational Therapist |
NPI Registry JSON
The complete NPPES record for this NPI in the NPI Registry API format.
{
"created_epoch": "1438732800000",
"enumeration_type": "NPI-1",
"last_updated_epoch": "1438732800000",
"number": "1952787533",
"addresses": [
{
"country_code": "US",
"country_name": "United States",
"address_purpose": "MAILING",
"address_type": "DOM",
"address_1": "170 COREY RD",
"address_2": "BRIGHTON HOUSE REHABILITATION AND NURSING CENTER",
"city": "BRIGHTON",
"state": "MA",
"postal_code": "02135",
"telephone_number": "617-731-0515"
},
{
"country_code": "US",
"country_name": "United States",
"address_purpose": "LOCATION",
"address_type": "DOM",
"address_1": "170 COREY RD",
"address_2": "BRIGHTON HOUSE REHABILITATION AND NURSING CENTER",
"city": "BRIGHTON",
"state": "MA",
"postal_code": "02135",
"telephone_number": "617-731-0515"
}
],
"practiceLocations": [],
"basic": {
"last_name": "WALLACE",
"first_name": "KENNETH",
"credential": "PTA",
"sole_proprietor": "NO",
"sex": "M",
"enumeration_date": "2015-08-05",
"last_updated": "2015-08-05",
"status": "A"
},
"taxonomies": [
{
"code": "225200000X",
"taxonomy_group": "",
"desc": "Physical Therapy Assistant",
"state": "MA",
"license": "8869",
"primary": true
}
],
"identifiers": [],
"endpoints": [],
"other_names": []
}Other providers in Brighton, MA
Sources for this page
- NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Aug 5, 2015; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
- National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.