Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 225XN1300X | Occupational Therapist - Neurorehabilitation | OT008010 | GA |
NPI | 1366105892 |
---|---|
Provider Name | Julia Danielle Wallace |
First Address | Atlanta, GA 30316-1266 |
Second Address | Lawrenceville, GA 30043-5065 |
Gender | F |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 21/10/2021 |
Last Update Date | 21/10/2021 |