Individual
AMY CATHERINE WALLACE
Active
Sole proprietor
No
Provider details
NPI number
Gender
F
Credential
O.T.
Contact information
Practice address
2920 RONALD REAGAN BLVD, STE 110, CUMMING, GA 30041
(770) 889-0885
(770) 880-0886
Mailing address
2920 RONALD REAGAN BLVD, STE 110, CUMMING, GA 30041
(770) 889-0885
(770) 880-0886
Taxonomy
Speciality
Code
Description
License number
State
225X00000X
Occupational Therapist
OT004063
GA
225XH1200X
Hand Occupational Therapist
Primary
—
—
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
1376695627
BCBS
GA
01
—
611446156001
TRICARE NUMBER
—
05
—
899040116A
—
GA
Enumeration date
01/17/2007
Last updated
12/13/2013
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