Provider Demographics
NPI:1104462639
Name:WALLACE-EWING, VERONICA
Entity type:Individual
Prefix:
First Name:VERONICA
Middle Name:
Last Name:WALLACE-EWING
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:201 HUSSON AVE APT R6
Mailing Address - Street 2:
Mailing Address - City:BANGOR
Mailing Address - State:ME
Mailing Address - Zip Code:04401-3241
Mailing Address - Country:US
Mailing Address - Phone:207-402-4345
Mailing Address - Fax:
Practice Address - Street 1:36 WORKMAN TER
Practice Address - Street 2:
Practice Address - City:LINCOLN
Practice Address - State:ME
Practice Address - Zip Code:04457-1162
Practice Address - Country:US
Practice Address - Phone:207-794-6025
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-11-19
Last Update Date:2019-11-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MEOT3720225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist