Provider Demographics
NPI:1891538070
Name:WALLACE, ELI WILLIAM (OT)
Entity type:Individual
Prefix:
First Name:ELI
Middle Name:WILLIAM
Last Name:WALLACE
Suffix:
Gender:M
Credentials:OT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:105 CONCERTO CRST
Mailing Address - Street 2:
Mailing Address - City:DUSON
Mailing Address - State:LA
Mailing Address - Zip Code:70529-3352
Mailing Address - Country:US
Mailing Address - Phone:337-258-5264
Mailing Address - Fax:
Practice Address - Street 1:400 POLLY LN
Practice Address - Street 2:
Practice Address - City:LAFAYETTE
Practice Address - State:LA
Practice Address - Zip Code:70508-4966
Practice Address - Country:US
Practice Address - Phone:337-443-0652
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-06-17
Last Update Date:2024-06-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LAOTT.200733225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist