Provider Demographics
NPI:1992273841
Name:WALLACE, PETER KENNEDY (OTR/L)
Entity type:Individual
Prefix:
First Name:PETER
Middle Name:KENNEDY
Last Name:WALLACE
Suffix:
Gender:M
Credentials:OTR/L
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:652 S MEDICAL CENTER DR
Mailing Address - Street 2:
Mailing Address - City:ST GEORGE
Mailing Address - State:UT
Mailing Address - Zip Code:84790-7049
Mailing Address - Country:US
Mailing Address - Phone:435-251-3760
Mailing Address - Fax:
Practice Address - Street 1:166 W 1325 N STE 100
Practice Address - Street 2:
Practice Address - City:CEDAR CITY
Practice Address - State:UT
Practice Address - Zip Code:84721-7793
Practice Address - Country:US
Practice Address - Phone:435-586-0064
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-11-08
Last Update Date:2018-11-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT10533523-4201225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist