Individual
MRS. BEVERLY WALLACE
Active
Sole proprietor
Provider details
NPI number
Gender
F
Credential
OTR/L
Contact information
Practice address
3911 GOLF PARK LOOP, SUITE #105, BRADENTON, FL 34203-3453
(941) 756-1003
(941) 756-6003
Mailing address
6477 INDIGO BUNTING PL, BRADENTON, FL 34202-8246
(941) 756-1003
(941) 756-6003
Taxonomy
Speciality
Code
Description
License number
State
225X00000X
Occupational Therapist
Primary
OT9730
FL
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
Y902F
BCBS
FL
Enumeration date
02/02/2006
Last updated
07/09/2007
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