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NPI Code Detail

MEDICARE: MARY WALLACE OTR

MEDICARE: MARY WALLACE OTR
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
1225X00000XOccupational Therapist2022037104MO

General Provider Information

NPI Number : 1689398141
Entity Type Code : Individual
Provider Name (Legal Business Name) : MARY WALLACE OTR
Provider Business Mailing Address
First Line : 7527 TEASDALE AVE
Second Line :
City : SAINT LOUIS
State : MO
Zip : 63130-3923
Country : US
Telephone Number :
Fax Number :
Provider Business Practice Location Address
First Line : 2150 W RANDOLPH ST
Second Line :
City : SAINT CHARLES
State : MO
Zip : 63301-0844
Country : US
Telephone Number : 636-946-4966
Fax Number :
Authorized Official
Title or Position :
Name :
Credential :
Telephone Number :
Provider Enumeration Date : 09/28/2022
Last Update Date : 04/14/2023

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