Provider Demographics
NPI:1659912756
Name:WALLACE, FALLON (COTA)
Entity Type:Individual
Prefix:
First Name:FALLON
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 1:342 LYNDA LN
Mailing Address - Street 2:
Mailing Address - City:LEXINGTON
Mailing Address - State:NC
Mailing Address - Zip Code:27295-7948
Mailing Address - Country:US
Mailing Address - Phone:336-239-1465
Mailing Address - Fax:
Practice Address - Street 1:22822 MYRTLE ST
Practice Address - Street 2:
Practice Address - City:HAYWARD
Practice Address - State:CA
Practice Address - Zip Code:94541-6321
Practice Address - Country:US
Practice Address - Phone:510-537-4844
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-10-01
Last Update Date:2019-10-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAOTA4830224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant