Provider Demographics
NPI:1073730636
Name:WALLACE, DANA JILL (MS, OTR/L)
Entity Type:Individual
Prefix:MRS
First Name:DANA
Middle Name:JILL
Last Name:WALLACE
Suffix:
Gender:F
Credentials:MS, OTR/L
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:20925 PROFESSIONAL PLAZA
Mailing Address - Street 2:SUITE 300
Mailing Address - City:ASHBURN
Mailing Address - State:VA
Mailing Address - Zip Code:20147
Mailing Address - Country:US
Mailing Address - Phone:703-544-7171
Mailing Address - Fax:703-997-4450
Practice Address - Street 1:20925 PROFESSIONAL PLAZA
Practice Address - Street 2:SUITE 300
Practice Address - City:ASHBURN
Practice Address - State:VA
Practice Address - Zip Code:20147
Practice Address - Country:US
Practice Address - Phone:703-544-7171
Practice Address - Fax:703-997-4450
Is Sole Proprietor?:No
Enumeration Date:2007-04-18
Last Update Date:2023-08-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAOT004212225X00000X
225XH1200X
VA0119005354225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist
No225XH1200XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational TherapistHand
Provider Identifiers
StateIdentifier IDID TypeIssuer
9519754OtherAETNA
976238-01OtherCAREFIRST MARYLAND
4695-0050OtherCAREFIRST NCA
243742YZWMedicare PIN