Provider Demographics
NPI:1679456701
Name:WALLACE, JOSIAH
Entity type:Individual
Prefix:
First Name:JOSIAH
Middle Name:
Last Name:WALLACE
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5405 LAURENE ST
Mailing Address - Street 2:
Mailing Address - City:FLINT
Mailing Address - State:MI
Mailing Address - Zip Code:48505-2572
Mailing Address - Country:US
Mailing Address - Phone:810-733-1072
Mailing Address - Fax:
Practice Address - Street 1:1032 S LINDEN RD
Practice Address - Street 2:
Practice Address - City:FLINT
Practice Address - State:MI
Practice Address - Zip Code:48532-3458
Practice Address - Country:US
Practice Address - Phone:810-733-3833
Practice Address - Fax:810-733-1072
Is Sole Proprietor?:No
Enumeration Date:2025-07-28
Last Update Date:2025-07-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5502008887APP25225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant