Provider Demographics
NPI:1467517466
Name:WALLACE, AMY ANN (OTR-L)
Entity Type:Individual
Prefix:
First Name:AMY
Middle Name:ANN
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:PO BOX 9578
Mailing Address - Street 2:
Mailing Address - City:SOUTH LAKE TAHOE
Mailing Address - State:CA
Mailing Address - Zip Code:96158
Mailing Address - Country:US
Mailing Address - Phone:530-543-5896
Mailing Address - Fax:530-544-6512
Practice Address - Street 1:10539 PROFESSIONAL CIR
Practice Address - Street 2:SUITE 201
Practice Address - City:SOUTH LAKE TAHOE
Practice Address - State:CA
Practice Address - Zip Code:96150-3828
Practice Address - Country:US
Practice Address - Phone:775-348-8800
Practice Address - Fax:833-687-1419
Is Sole Proprietor?:No
Enumeration Date:2006-12-27
Last Update Date:2023-07-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA3665225X00000X
NV0721225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist