Provider Demographics
NPI:1598904427
Name:WALLACE, SUSAN LEIGH (OTR/L)
Entity Type:Individual
Prefix:MRS
First Name:SUSAN
Middle Name:LEIGH
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 1:103 WINDWOOD ROAD
Mailing Address - Street 2:
Mailing Address - City:NORTH SYRACUSE
Mailing Address - State:NY
Mailing Address - Zip Code:13212-1956
Mailing Address - Country:US
Mailing Address - Phone:315-458-9923
Mailing Address - Fax:
Practice Address - Street 1:103 WINDWOOD RD
Practice Address - Street 2:
Practice Address - City:NORTH SYRACUSE
Practice Address - State:NY
Practice Address - Zip Code:13212-1956
Practice Address - Country:US
Practice Address - Phone:315-458-9923
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-02-17
Last Update Date:2024-03-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY0004671174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist