Individual
KEITH WALLACE
Active
Sole proprietor
Yes
Provider details
NPI number
Gender
Man
Contact information
Practice address
4902 S VAL VISTA DR, SUITE B102, GILBERT, AZ 85298-7325
(480) 855-8866
Mailing address
9432 E CONQUISTADORES DR, SCOTTSDALE, AZ 85255-4343
(602) 703-0748
Taxonomy
Speciality
Code
Description
License number
State
224Z00000X
Occupational Therapy Assistant
Primary
5853
AZ
Other
Enumeration date
05/15/2015
Last updated
05/15/2015
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