Provider Demographics
NPI:1861679060
Name:WALLACE, DAWN MICHELLE (COTA/L)
Entity type:Individual
Prefix:MISS
First Name:DAWN
Middle Name:MICHELLE
Last Name:WALLACE
Suffix:
Gender:F
Credentials:COTA/L
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:97 HUGHES RD STE H
Mailing Address - Street 2:
Mailing Address - City:MADISON
Mailing Address - State:AL
Mailing Address - Zip Code:35758-3401
Mailing Address - Country:US
Mailing Address - Phone:256-883-7338
Mailing Address - Fax:
Practice Address - Street 1:97 HUGHES RD STE H
Practice Address - Street 2:
Practice Address - City:MADISON
Practice Address - State:AL
Practice Address - Zip Code:35758-3401
Practice Address - Country:US
Practice Address - Phone:256-883-7338
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-01-30
Last Update Date:2010-11-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AL0754224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant