Provider records sourced from NPPES (CMS National Plan & Provider Enumeration System). Data current as of August 10, 2026.
NPIDirectory

Brandon Wallace, PT

Individual provider Physical Therapist · NPI 1700395274

Brandon Wallace, PT is a Physical Therapist in Private Practice in Southfield, Michigan. Qualified in 2017, 9 years ago. Practices with Cks of Mt Clemens LLC, an 18-clinician group and accepts Medicare assignment. Licensed in Michigan.

Years since qualifying
9
Licensed in
MI
In the registry since
2017
What do these letters mean?
PT — Physical Therapist
A licensed therapist who treats movement, pain and injury.

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Practice location Address checks out

29900 Southfield Rd
Southfield, MI 48076-2090
Phone: (248) 663-0400
Fax: (248) 621-5003
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Pin is approximate — placed at the ZIP-code centre, not the exact door.

Specialties & licences

Physical Therapist (primary) Taxonomy 225100000X · Licence 5501018432 (MI)

Record details

NPI number1700395274
Entity typeIndividual (Type 1)
GenderMale
Credentials PT
Sole proprietorNo
NPI enumeratedSeptember 27, 2017
Last updated in NPPESSeptember 27, 2017
Mailing address790 Remington Blvd, Bolingbrook, IL 60440-4909

Medicare enrollment

From the CMS Doctors & Clinicians file — this clinician is enrolled in Medicare.

Medicare specialtyPHYSICAL THERAPIST IN PRIVATE PRACTICE
Medical schoolOTHER
Graduated 2017 (9 years in practice)
Group practice Cks Of Mt Clemens Llc — 18 clinicians
Accepts Medicare assignment Yes — accepts the Medicare-approved amount
Practice locations2 on file with Medicare

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