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General NPI Number Information
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NPI Number | 1609821636
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Entity Type | Individual
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Provider Name | MR. BRADFORD ANTHONY WALLACE JR.
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Gender | Male
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Dates
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Enumeration Date | 05/25/2006
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Last Update Date | 07/08/2007
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Provider Practice Location Address
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Address Line | 130 EXECUTIVE DR
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City | NEWARK
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State | DE
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Zip | 19702-3349
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Country | US
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Telephone | 302-292-3454
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Fax | 302-292-3464
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Provider Business Mailing Address
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Address Line | 2327 PENNSYLVANIA AVE
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City | WILMINGTON
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State | DE
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Zip | 19806-1318
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Country | US
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Telephone | 302-571-9567
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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 | 224Z00000X
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Taxonomy Name | Occupational Therapy Assistant
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License Number | J2-0000629
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License Number State | DE
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