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General NPI Number Information
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NPI Number | 1366105892
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Entity Type | Individual
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Provider Name | JULIA DANIELLE WALLACE OTR/L
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Gender | Female
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Dates
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Enumeration Date | 10/21/2021
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Last Update Date | 10/21/2021
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Provider Practice Location Address
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Address Line | 1860 ATKINSON RD
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City | LAWRENCEVILLE
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State | GA
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Zip | 30043-5065
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Country | US
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Telephone | 706-948-2773
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Fax |
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Provider Business Mailing Address
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Address Line | 110 PEARL ST SE APT 4
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City | ATLANTA
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State | GA
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Zip | 30316-1266
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Country | US
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Telephone | 404-397-8655
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 225XN1300X
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Taxonomy Name | Neurorehabilitation Occupational Therapist
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License Number | OT008010
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License Number State | GA
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