Provider Demographics
NPI:1689953531
Name:WALLACH, BRITNI J (OTR)
Entity Type:Individual
Prefix:
First Name:BRITNI
Middle Name:J
Last Name:WALLACH
Suffix:
Gender:F
Credentials:OTR
Other - Prefix:
Other - First Name:BRITNI
Other - Middle Name:J
Other - Last Name:CARNAKO
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:P.O. BOX 608
Mailing Address - Street 2:
Mailing Address - City:SIKESTON
Mailing Address - State:MO
Mailing Address - Zip Code:63801-0608
Mailing Address - Country:US
Mailing Address - Phone:573-472-0397
Mailing Address - Fax:573-472-0409
Practice Address - Street 1:2061 PEAR TREE CT
Practice Address - Street 2:APT 5
Practice Address - City:CAPE GIRARDEAU
Practice Address - State:MO
Practice Address - Zip Code:63701-2111
Practice Address - Country:US
Practice Address - Phone:618-593-9218
Practice Address - Fax:573-472-0409
Is Sole Proprietor?:No
Enumeration Date:2011-08-10
Last Update Date:2024-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2011023399225X00000X
IL056011006225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist