Provider Demographics
NPI:1003490228
Name:WALLACE, RAYMOND M (COTA/L)
Entity Type:Individual
Prefix:
First Name:RAYMOND
Middle Name:M
Last Name:WALLACE
Suffix:
Gender:M
Credentials:COTA/L
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6956 S 310TH EAST AVE
Mailing Address - Street 2:
Mailing Address - City:BROKEN ARROW
Mailing Address - State:OK
Mailing Address - Zip Code:74014-5491
Mailing Address - Country:US
Mailing Address - Phone:918-230-8099
Mailing Address - Fax:
Practice Address - Street 1:6956 S 310TH EAST AVE
Practice Address - Street 2:
Practice Address - City:BROKEN ARROW
Practice Address - State:OK
Practice Address - Zip Code:74014-5491
Practice Address - Country:US
Practice Address - Phone:918-230-8099
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-05-12
Last Update Date:2021-05-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK569224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant