Provider Demographics
NPI:1376695627
Name:WALLACE, AMY CATHERINE (OT)
Entity Type:Individual
Prefix:
First Name:AMY
Middle Name:CATHERINE
Last Name:WALLACE
Suffix:
Gender:F
Credentials:OT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2920 RONALD REAGAN BLVD
Mailing Address - Street 2:STE 110
Mailing Address - City:CUMMING
Mailing Address - State:GA
Mailing Address - Zip Code:30041
Mailing Address - Country:US
Mailing Address - Phone:770-889-0885
Mailing Address - Fax:770-880-0886
Practice Address - Street 1:2920 RONALD REAGAN BLVD
Practice Address - Street 2:STE 110
Practice Address - City:CUMMING
Practice Address - State:GA
Practice Address - Zip Code:30041
Practice Address - Country:US
Practice Address - Phone:770-889-0885
Practice Address - Fax:770-880-0886
Is Sole Proprietor?:No
Enumeration Date:2007-01-17
Last Update Date:2013-12-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAOT004063225X00000X
225XH1200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225XH1200XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational TherapistHand
No225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA899040116AMedicaid
GA1376695627OtherBCBS
611446156001OtherTRICARE NUMBER
GA511I670012Medicare PIN