Provider Demographics
NPI:1437455219
Name:WALLACE, KRISTIN MARIE (OTR/L)
Entity Type:Individual
Prefix:
First Name:KRISTIN
Middle Name:MARIE
Last Name:WALLACE
Suffix:
Gender:F
Credentials:OTR/L
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2110 WASHINGTON BLVD STE. 158
Mailing Address - Street 2:
Mailing Address - City:ARLINGTON
Mailing Address - State:VA
Mailing Address - Zip Code:22204
Mailing Address - Country:US
Mailing Address - Phone:202-427-8290
Mailing Address - Fax:
Practice Address - Street 1:2110 WASHINGTON BLVD STE. 158
Practice Address - Street 2:
Practice Address - City:ARLINGTON
Practice Address - State:VA
Practice Address - Zip Code:22204
Practice Address - Country:US
Practice Address - Phone:202-427-8290
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-01-27
Last Update Date:2019-01-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0119004399225XH1300X
DC010000508225XH1300X
OR220439225XH1300X
NM2758225XH1300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225XH1300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational TherapistHuman Factors