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Individual
MS. LESLIE ANN WALLACE
Active
Individual
MS. LESLIE ANN WALLACE
Active
Sole proprietor
Yes
Provider details
NPI number
Gender
F
Credential
OT
Taxonomy
Speciality
Code
Description
License number
State
225X00000X
Occupational Therapist
Primary
186
MT
225XP0200X
Pediatric Occupational Therapist
186
MT
Other
Other identifiers
Code
Description
Identifier
Issuer
State
05
—
0341343
—
MT
01
—
66351
BCBS PROVIDER NUMBER
MT
Enumeration date
12/18/2006
Last updated
09/11/2025
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