MEDICARE: JULIA DANIELLE WALLACE OTR/L

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	225XN1300X	Neurorehabilitation Occupational Therapist	OT008010	GA

General Provider Information

NPI Number	:	1366105892
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	JULIA DANIELLE WALLACE OTR/L

Provider Business Mailing Address
First Line	:	110 PEARL ST SE APT 4
Second Line	:
City	:	ATLANTA
State	:	GA
Zip	:	30316-1266
Country	:	US
Telephone Number	:	404-397-8655
Fax Number	:

Provider Business Practice Location Address
First Line	:	1860 ATKINSON RD
Second Line	:
City	:	LAWRENCEVILLE
State	:	GA
Zip	:	30043-5065
Country	:	US
Telephone Number	:	706-948-2773
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	10/21/2021
Last Update Date	:	10/21/2021

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