Provider Demographics
NPI:1114627593
Name:WALLACE, CAMILLE N (OTD, OTR/L)
Entity Type:Individual
Prefix:DR
First Name:CAMILLE
Middle Name:N
Last Name:WALLACE
Suffix:
Gender:F
Credentials:OTD, OTR/L
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1315 YOSEMITE DR
Mailing Address - Street 2:
Mailing Address - City:COLORADO SPRINGS
Mailing Address - State:CO
Mailing Address - Zip Code:80910-2044
Mailing Address - Country:US
Mailing Address - Phone:620-875-0389
Mailing Address - Fax:
Practice Address - Street 1:1130 W WOODMEN RD
Practice Address - Street 2:
Practice Address - City:COLORADO SPRINGS
Practice Address - State:CO
Practice Address - Zip Code:80919-2726
Practice Address - Country:US
Practice Address - Phone:719-574-5562
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-03-06
Last Update Date:2023-03-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
COOT.0007644225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist