Provider Demographics
NPI:1639112071
Name:WALLACE, TERRY (LOT)
Entity Type:Individual
Prefix:
First Name:TERRY
Middle Name:
Last Name:WALLACE
Suffix:
Gender:M
Credentials:LOT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2154 RIVER VILLAGE DR
Mailing Address - Street 2:
Mailing Address - City:HUMBLE
Mailing Address - State:TX
Mailing Address - Zip Code:77339-1770
Mailing Address - Country:US
Mailing Address - Phone:281-361-3829
Mailing Address - Fax:
Practice Address - Street 1:605 ROCKMEAD DR
Practice Address - Street 2:SUITE 200
Practice Address - City:HUMBLE
Practice Address - State:TX
Practice Address - Zip Code:77339-2254
Practice Address - Country:US
Practice Address - Phone:281-348-9588
Practice Address - Fax:281-348-2150
Is Sole Proprietor?:No
Enumeration Date:2006-06-14
Last Update Date:2009-02-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX104330225X00000X
TX1041100564225XH1200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist
No225XH1200XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational TherapistHand
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX104330OtherOCCUPATIONAL THERAPY LICENSE
TX8A7555Medicare UPIN