Provider Demographics
NPI:1316134638
Name:WALLACE, LAURA STEWART (OT)
Entity type:Individual
Prefix:
First Name:LAURA
Middle Name:STEWART
Last Name:WALLACE
Suffix:
Gender:F
Credentials:OT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1 PARK AVE
Mailing Address - Street 2:SUITE F
Mailing Address - City:MOUNT AIRY
Mailing Address - State:MD
Mailing Address - Zip Code:21771-5437
Mailing Address - Country:US
Mailing Address - Phone:301-607-8383
Mailing Address - Fax:301-829-8640
Practice Address - Street 1:1 PARK AVE
Practice Address - Street 2:SUITE F
Practice Address - City:MOUNT AIRY
Practice Address - State:MD
Practice Address - Zip Code:21771-5437
Practice Address - Country:US
Practice Address - Phone:301-607-8383
Practice Address - Fax:301-829-8640
Is Sole Proprietor?:No
Enumeration Date:2007-10-01
Last Update Date:2007-10-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MD01641225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist