Individual
RAYMOND M WALLACE
Active
Sole proprietor
Yes
Provider details
NPI number
Gender
Man
Credential
COTA/L
Contact information
Practice address
6956 S 310TH EAST AVE, BROKEN ARROW, OK 74014-5491
(918) 230-8099
Mailing address
6956 S 310TH EAST AVE, BROKEN ARROW, OK 74014-5491
(918) 230-8099
Taxonomy
Speciality
Code
Description
License number
State
224Z00000X
Occupational Therapy Assistant
Primary
569
OK
Other
Enumeration date
05/12/2021
Last updated
05/12/2021
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