Provider Demographics
NPI:1750990198
Name:WALLACE WELLNESS THERAPY & PERFORMANCE LLC
Entity type:Organization
Organization Name:WALLACE WELLNESS THERAPY & PERFORMANCE LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OCCUPATIONAL THERAPIST OTR/L
Authorized Official - Prefix:
Authorized Official - First Name:LANEE
Authorized Official - Middle Name:ARLETT
Authorized Official - Last Name:WALLACE
Authorized Official - Suffix:
Authorized Official - Credentials:MOT, OTR/L
Authorized Official - Phone:330-402-7541
Mailing Address - Street 1:45752 UTICA PARK BLVD
Mailing Address - Street 2:
Mailing Address - City:UTICA
Mailing Address - State:MI
Mailing Address - Zip Code:48315-5950
Mailing Address - Country:US
Mailing Address - Phone:330-402-7541
Mailing Address - Fax:
Practice Address - Street 1:45752 UTICA PARK BLVD
Practice Address - Street 2:
Practice Address - City:UTICA
Practice Address - State:MI
Practice Address - Zip Code:48315-5950
Practice Address - Country:US
Practice Address - Phone:330-402-7541
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-07-30
Last Update Date:2020-07-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational TherapistGroup - Single Specialty