Healthcare Provider Details

I. General information

NPI: 1033256029
Provider Name (Legal Business Name): MICHELLE WALLACE ALLEN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/31/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

13424 WELBY CT
MIDLOTHIAN VA
23113-3662
US

IV. Provider business mailing address

1705 HEADWATERS RD
MIDLOTHIAN VA
23113-4033
US

V. Phone/Fax

Practice location:
  • Phone: 804-986-7224
  • Fax:
Mailing address:
  • Phone: 804-379-4014
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225XP0200X
TaxonomyPediatric Occupational Therapist
License Number0119001250
License Number StateVA

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: