Provider Demographics
NPI:1992043210
Name:WALLACE, COLLEEN THERESE (COTA)
Entity Type:Individual
Prefix:MRS
First Name:COLLEEN
Middle Name:THERESE
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 1:9286 ARPIN RICHFIELD RD
Mailing Address - Street 2:
Mailing Address - City:ARPIN
Mailing Address - State:WI
Mailing Address - Zip Code:54410-9514
Mailing Address - Country:US
Mailing Address - Phone:715-897-4213
Mailing Address - Fax:
Practice Address - Street 1:9286 ARPIN RICHFIELD RD
Practice Address - Street 2:
Practice Address - City:ARPIN
Practice Address - State:WI
Practice Address - Zip Code:54410-9514
Practice Address - Country:US
Practice Address - Phone:715-897-4213
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-01-21
Last Update Date:2013-01-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI1032-27314000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI1032-27Medicaid