MEDICARE: NOREEN 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	225X00000X	Occupational Therapist	00042	CT

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier Issuer
1	2V8290	OTHER	ORTHONET
2	747741	OTHER	CONNECTICARE
3	P815837	OTHER	OXFORD
4	130000442CT01	OTHER	ANTHEM BLUE CROSS BLUE SH
5	2957257	OTHER	AETNA
6	OV7803	OTHER	HEALTHNET

General Provider Information

NPI Number	:	1366518771
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	NOREEN WALLACE OTR L

Provider Business Mailing Address
First Line	:	PO BOX 397
Second Line	:
City	:	WOODSTOCK
State	:	CT
Zip	:	06281
Country	:	US
Telephone Number	:	860-963-0712
Fax Number	:	860-963-0712

Provider Business Practice Location Address
First Line	:	602 RTE 169
Second Line	:
City	:	WOODSTOCK
State	:	CT
Zip	:	06281
Country	:	US
Telephone Number	:	860-963-0712
Fax Number	:	860-963-0712

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

Provider Enumeration Date	:	11/28/2006
Last Update Date	:	09/19/2011

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