Individual
MR. BLAKE WALLACE
Active
Sole proprietor
Yes
Provider details
NPI number
Gender
Man
Contact information
Practice address
7820 WALKING HORSE CIR, GERMANTOWN, TN 38138-2143
(901) 752-2500
Mailing address
150 EVANSVILLE RD, COLDWATER, MS 38618-6778
(662) 561-5655
Taxonomy
Speciality
Code
Description
License number
State
224Z00000X
Occupational Therapy Assistant
Primary
TA3704
MS
Other
Enumeration date
04/12/2020
Last updated
04/12/2020
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