Provider Demographics
NPI:1669768925
Name:WALLACE, ROBIN (COTA)
Entity type:Individual
Prefix:
First Name:ROBIN
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 1:15700 WYOMING DR
Mailing Address - Street 2:
Mailing Address - City:FRISCO
Mailing Address - State:TX
Mailing Address - Zip Code:75035-6696
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:15700 WYOMING DR
Practice Address - Street 2:SUITE 221
Practice Address - City:FRISCO
Practice Address - State:TX
Practice Address - Zip Code:75035-6696
Practice Address - Country:US
Practice Address - Phone:908-894-0532
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-06-24
Last Update Date:2015-11-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX212138224Z00000X
CAOTA1369224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant