Healthcare Provider Details

I. General information

NPI: 1588574552
Provider Name (Legal Business Name): LAURIE ANN WALLACE OTR
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/10/2026
Last Update Date: 09/10/2026
Certification Date: 09/10/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

115 FILLOW ST APT 68
NORWALK CT
06850-2846
US

IV. Provider business mailing address

115 FILLOW ST APT 68
NORWALK CT
06850-2846
US

V. Phone/Fax

Practice location:
  • Phone: 203-219-2390
  • Fax:
Mailing address:
  • Phone: 203-219-2390
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225X00000X
TaxonomyOccupational Therapist
License Number000461
License Number StateCT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: