Provider Demographics
NPI:1548749328
Name:WALLACE, GRACE (COTA)
Entity Type:Individual
Prefix:
First Name:GRACE
Middle Name:
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 1:2210 W DALLAS ST APT 1522
Mailing Address - Street 2:
Mailing Address - City:HOUSTON
Mailing Address - State:TX
Mailing Address - Zip Code:77019-4356
Mailing Address - Country:US
Mailing Address - Phone:781-626-3729
Mailing Address - Fax:
Practice Address - Street 1:2210 W DALLAS ST APT 1522
Practice Address - Street 2:
Practice Address - City:HOUSTON
Practice Address - State:TX
Practice Address - Zip Code:77019-4356
Practice Address - Country:US
Practice Address - Phone:781-626-3729
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-08-12
Last Update Date:2018-08-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX215123224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant