Provider Demographics
NPI:1740936517
Name:WALLACE, WHITNEY LEA (COTA/L)
Entity type:Individual
Prefix:
First Name:WHITNEY
Middle Name:LEA
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 1:3721 FAULKNER DR APT 117
Mailing Address - Street 2:
Mailing Address - City:LINCOLN
Mailing Address - State:NE
Mailing Address - Zip Code:68516-4763
Mailing Address - Country:US
Mailing Address - Phone:308-870-3193
Mailing Address - Fax:
Practice Address - Street 1:624 PINEWOOD AVE
Practice Address - Street 2:
Practice Address - City:SEWARD
Practice Address - State:NE
Practice Address - Zip Code:68434-1055
Practice Address - Country:US
Practice Address - Phone:402-643-2902
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-03-01
Last Update Date:2022-03-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NE1074224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant