Individual
DR. BASIA C. Z. WALLACE
Active
Sole proprietor
No
Provider details
NPI number
Gender
F
Credential
OTD, OTR/L
Contact information
Practice address
394 FEDERAL DR, CRYSTAL LAKE, IL 60014
(815) 459-3810
(815) 356-3550
Mailing address
394 FEDERAL DR, CRYSTAL LAKE, IL 60014-6281
(815) 459-3810
(815) 356-3550
Taxonomy
Speciality
Code
Description
License number
State
225X00000X
Occupational Therapist
Primary
056.015836
IL
Other
Enumeration date
12/18/2023
Last updated
12/18/2023
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