Basic Information
| Provider Information | |||||||||
| NPI: | 1568908952 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | WALLACE | ||||||||
| FirstName: | KATELYN | ||||||||
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| Mailing Information | |||||||||
| Address1: | 3000 GOFFS FALLS RD | ||||||||
| Address2: | STE 101 | ||||||||
| City: | MANCHESTER | ||||||||
| State: | NH | ||||||||
| PostalCode: | 031111000 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8009952673 | ||||||||
| FaxNumber: | 8889796551 | ||||||||
| Practice Location | |||||||||
| Address1: | 3000 GOFFS FALLS RD | ||||||||
| Address2: | STE 101 | ||||||||
| City: | MANCHESTER | ||||||||
| State: | NH | ||||||||
| PostalCode: | 031111000 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8009952673 | ||||||||
| FaxNumber: | 8889796551 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/10/2017 | ||||||||
| LastUpdateDate: | 01/10/2017 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225X00000X | 0119006994 | VA | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Occupational Therapist |
No ID Information.