Provider Demographics
NPI:1629746904
Name:WALLACE, CHRISTOPHER GEORGE (OTR/L)
Entity Type:Individual
Prefix:
First Name:CHRISTOPHER
Middle Name:GEORGE
Last Name:WALLACE
Suffix:
Gender:M
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 1:305 HAINES DR
Mailing Address - Street 2:
Mailing Address - City:NORTH WALES
Mailing Address - State:PA
Mailing Address - Zip Code:19454-2702
Mailing Address - Country:US
Mailing Address - Phone:215-360-9314
Mailing Address - Fax:
Practice Address - Street 1:6595 ROOSEVELT BLVD
Practice Address - Street 2:
Practice Address - City:PHILADELPHIA
Practice Address - State:PA
Practice Address - Zip Code:19149-2998
Practice Address - Country:US
Practice Address - Phone:215-743-2332
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-09-01
Last Update Date:2021-09-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAOC017968225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist