Healthcare Provider Details

I. General information

NPI: 1538297544
Provider Name (Legal Business Name): KRISTEN WALLACE OT
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: KRISTEN PEDERSEN

II. Dates (important events)

Enumeration Date: 03/01/2007
Last Update Date: 04/06/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5959 CORSON AVE S
SEATTLE WA
98108-2605
US

IV. Provider business mailing address

1200 CORPORATE DR STE 400
BIRMINGHAM AL
35242-5424
US

V. Phone/Fax

Practice location:
  • Phone: 206-971-7466
  • Fax: 206-971-7515
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225X00000X
TaxonomyOccupational Therapist
License Number01326
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: