Provider Demographics
NPI:1518235886
Name:WALLACE, RHONDA KAY (OTR/L)
Entity Type:Individual
Prefix:MRS
First Name:RHONDA
Middle Name:KAY
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 1:18 COTTON ROW
Mailing Address - Street 2:
Mailing Address - City:MEDINA
Mailing Address - State:TN
Mailing Address - Zip Code:38355-9810
Mailing Address - Country:US
Mailing Address - Phone:731-437-0068
Mailing Address - Fax:
Practice Address - Street 1:2031 AVONDALE ST
Practice Address - Street 2:
Practice Address - City:HUMBOLDT
Practice Address - State:TN
Practice Address - Zip Code:38343-1810
Practice Address - Country:US
Practice Address - Phone:731-784-3655
Practice Address - Fax:731-784-3651
Is Sole Proprietor?:No
Enumeration Date:2011-12-01
Last Update Date:2011-12-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN356225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist