Provider Demographics
NPI:1386410850
Name:WALLACE, TAYLOR (COTA/L)
Entity type:Individual
Prefix:
First Name:TAYLOR
Middle Name:
Last Name:WALLACE
Suffix:
Gender:F
Credentials:COTA/L
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:700 CHERRY TREE RD APT G2
Mailing Address - Street 2:
Mailing Address - City:UPPER CHICHESTER
Mailing Address - State:PA
Mailing Address - Zip Code:19014-2450
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:148 W STATE ST STE 103
Practice Address - Street 2:
Practice Address - City:KENNETT SQUARE
Practice Address - State:PA
Practice Address - Zip Code:19348-3055
Practice Address - Country:US
Practice Address - Phone:484-432-1614
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-11-27
Last Update Date:2023-11-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAOP009719224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant