Provider Demographics
NPI:1427847466
Name:WALLACE, TAYLOR TIDWELL (OTR/L, RN)
Entity type:Individual
Prefix:
First Name:TAYLOR
Middle Name:TIDWELL
Last Name:WALLACE
Suffix:
Gender:
Credentials:OTR/L, RN
Other - Prefix:
Other - First Name:TAYLOR
Other - Middle Name:GRACE
Other - Last Name:TIDWELL
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:407 W BRIGHTON AVE
Mailing Address - Street 2:
Mailing Address - City:MUSCLE SHOALS
Mailing Address - State:AL
Mailing Address - Zip Code:35661-3201
Mailing Address - Country:US
Mailing Address - Phone:256-762-5576
Mailing Address - Fax:
Practice Address - Street 1:2904 S WILSON DAM RD
Practice Address - Street 2:
Practice Address - City:MUSCLE SHOALS
Practice Address - State:AL
Practice Address - Zip Code:35661-3752
Practice Address - Country:US
Practice Address - Phone:256-856-5800
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2025-05-05
Last Update Date:2025-05-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AL6039225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist