Individual
MARY WALLACE
Active
Sole proprietor
No
Provider details
NPI number
Gender
F
Credential
OTR
Contact information
Practice address
2150 W RANDOLPH ST, SAINT CHARLES, MO 63301-0844
(636) 946-4966
Mailing address
7527 TEASDALE AVE, SAINT LOUIS, MO 63130-3923
Taxonomy
Speciality
Code
Description
License number
State
225X00000X
Occupational Therapist
Primary
2022037104
MO
Other
Enumeration date
09/28/2022
Last updated
04/14/2023
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