Provider Demographics
NPI:1396368064
Name:WALLACE, LISA JEAN (COTA)
Entity Type:Individual
Prefix:
First Name:LISA
Middle Name:JEAN
Last Name:WALLACE
Suffix:
Gender:F
Credentials:COTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:77 MADISON AVE
Mailing Address - Street 2:
Mailing Address - City:MORRISTOWN
Mailing Address - State:NJ
Mailing Address - Zip Code:07960-7330
Mailing Address - Country:US
Mailing Address - Phone:973-540-9800
Mailing Address - Fax:
Practice Address - Street 1:480 SOMERSET ST UNIT 1
Practice Address - Street 2:
Practice Address - City:NORTH PLAINFIELD
Practice Address - State:NJ
Practice Address - Zip Code:07060-4018
Practice Address - Country:US
Practice Address - Phone:954-292-3295
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-05-28
Last Update Date:2020-05-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ46TA09127800224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant