Provider Demographics
NPI:1295950244
Name:WALLACE, DEBORAH A
Entity type:Individual
Prefix:
First Name:DEBORAH
Middle Name:A
Last Name:WALLACE
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1036 BORDEN DR
Mailing Address - Street 2:
Mailing Address - City:ROSELLE
Mailing Address - State:IL
Mailing Address - Zip Code:60172-1706
Mailing Address - Country:US
Mailing Address - Phone:312-942-7173
Mailing Address - Fax:312-942-5094
Practice Address - Street 1:710 S PAULINA ST
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60612-3808
Practice Address - Country:US
Practice Address - Phone:312-942-7173
Practice Address - Fax:312-942-5094
Is Sole Proprietor?:No
Enumeration Date:2007-04-16
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist