Provider Demographics
NPI:1609821636
Name:WALLACE, BRADFORD ANTHONY JR
Entity Type:Individual
Prefix:MR
First Name:BRADFORD
Middle Name:ANTHONY
Last Name:WALLACE
Suffix:JR
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2327 PENNSYLVANIA AVE
Mailing Address - Street 2:
Mailing Address - City:WILMINGTON
Mailing Address - State:DE
Mailing Address - Zip Code:19806-1318
Mailing Address - Country:US
Mailing Address - Phone:302-571-9567
Mailing Address - Fax:
Practice Address - Street 1:130 EXECUTIVE DR
Practice Address - Street 2:
Practice Address - City:NEWARK
Practice Address - State:DE
Practice Address - Zip Code:19702-3349
Practice Address - Country:US
Practice Address - Phone:302-292-3454
Practice Address - Fax:302-292-3464
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-05-25
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
DEJ2-0000629224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant