Basic Information
| Provider Information | |||||||||
| NPI: | 1467517466 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | WALLACE | ||||||||
| FirstName: | AMY | ||||||||
| MiddleName: | ANN | ||||||||
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| Credential: | OTR-L | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 9578 | ||||||||
| Address2: | |||||||||
| City: | SOUTH LAKE TAHOE | ||||||||
| State: | CA | ||||||||
| PostalCode: | 961589578 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5305435896 | ||||||||
| FaxNumber: | 5305446512 | ||||||||
| Practice Location | |||||||||
| Address1: | 2170 SOUTH AVE | ||||||||
| Address2: | |||||||||
| City: | SOUTH LAKE TAHOE | ||||||||
| State: | CA | ||||||||
| PostalCode: | 961507026 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5305435896 | ||||||||
| FaxNumber: | 5305446512 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/27/2006 | ||||||||
| LastUpdateDate: | 03/17/2018 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225X00000X | 0721 | NV | N | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Occupational Therapist | 225X00000X | 3665 | CA | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Occupational Therapist |
No ID Information.