Provider Demographics
NPI:1982971750
Name:NELSON WALLACE, LAURIE SUE (OTR/L)
Entity Type:Individual
Prefix:MS
First Name:LAURIE
Middle Name:SUE
Last Name:NELSON WALLACE
Suffix:
Gender:F
Credentials:OTR/L
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11105 E SAHUARO DR
Mailing Address - Street 2:
Mailing Address - City:SCOTTSDALE
Mailing Address - State:AZ
Mailing Address - Zip Code:85259-3994
Mailing Address - Country:US
Mailing Address - Phone:480-296-8115
Mailing Address - Fax:
Practice Address - Street 1:4045 E UNION HILLS DR STE 110
Practice Address - Street 2:
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85050
Practice Address - Country:US
Practice Address - Phone:602-485-4444
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-11-22
Last Update Date:2018-08-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ4932225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist