Individual
AMANDA WALLACE
Active
Sole proprietor
No
Provider details
NPI number
Gender
F
Contact information
Practice address
829 FAIRMONT RD, MORGANTOWN, WV 26501-0088
(304) 305-1506
Mailing address
26 KIMBERLY CIR, FAIRMONT, WV 26554-7998
(304) 677-9611
Taxonomy
Speciality
Code
Description
License number
State
225X00000X
Occupational Therapist
Primary
1905
WV
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
1905
WVBOT
WV
Enumeration date
10/06/2022
Last updated
10/06/2022
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