Provider Demographics
NPI:1972070068
Name:WALLACE, ASHLEY LYNNE (COTA/L)
Entity type:Individual
Prefix:
First Name:ASHLEY
Middle Name:LYNNE
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 1:1000 US HIGHWAY 82 E
Mailing Address - Street 2:
Mailing Address - City:SHERMAN
Mailing Address - State:TX
Mailing Address - Zip Code:75090-1704
Mailing Address - Country:US
Mailing Address - Phone:903-893-9636
Mailing Address - Fax:
Practice Address - Street 1:1000 US HIGHWAY 82 E
Practice Address - Street 2:
Practice Address - City:SHERMAN
Practice Address - State:TX
Practice Address - Zip Code:75090-1704
Practice Address - Country:US
Practice Address - Phone:903-893-9636
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-10-27
Last Update Date:2018-10-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX215129224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant