Provider Demographics
NPI:1659921229
Name:WALLACE, TAYLOR ANN (COTA/L)
Entity Type:Individual
Prefix:MRS
First Name:TAYLOR
Middle Name:ANN
Last Name:WALLACE
Suffix:
Gender:F
Credentials:COTA/L
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4257 RUFE SNOW DR APT 622
Mailing Address - Street 2:
Mailing Address - City:NORTH RICHLAND HILLS
Mailing Address - State:TX
Mailing Address - Zip Code:76180-8572
Mailing Address - Country:US
Mailing Address - Phone:817-914-3148
Mailing Address - Fax:
Practice Address - Street 1:4257 RUFE SNOW DR APT 622
Practice Address - Street 2:
Practice Address - City:NORTH RICHLAND HILLS
Practice Address - State:TX
Practice Address - Zip Code:76180-8572
Practice Address - Country:US
Practice Address - Phone:817-914-3148
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-09-16
Last Update Date:2019-09-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX215778224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant