Provider Demographics
NPI:1215303102
Name:WALLIS, KAREN LYNN (OT/L)
Entity type:Individual
Prefix:MRS
First Name:KAREN
Middle Name:LYNN
Last Name:WALLIS
Suffix:
Gender:F
Credentials:OT/L
Other - Prefix:MISS
Other - First Name:KAREN
Other - Middle Name:LYNN
Other - Last Name:RICHARDS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:OT/L
Mailing Address - Street 1:135 MEADOW CIR
Mailing Address - Street 2:
Mailing Address - City:BEREA
Mailing Address - State:OH
Mailing Address - Zip Code:44017-2610
Mailing Address - Country:US
Mailing Address - Phone:440-243-2664
Mailing Address - Fax:
Practice Address - Street 1:135 MEADOW CIR
Practice Address - Street 2:
Practice Address - City:BEREA
Practice Address - State:OH
Practice Address - Zip Code:44017-2610
Practice Address - Country:US
Practice Address - Phone:440-243-2664
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-08-14
Last Update Date:2015-08-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH01756225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist