Provider Demographics
NPI:1023442860
Name:WALLACE, GAURI (OTR/L)
Entity type:Individual
Prefix:
First Name:GAURI
Middle Name:
Last Name:WALLACE
Suffix:
Gender:F
Credentials:OTR/L
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4 FAMILY CIR
Mailing Address - Street 2:
Mailing Address - City:LEE CENTER
Mailing Address - State:NY
Mailing Address - Zip Code:13363-9728
Mailing Address - Country:US
Mailing Address - Phone:315-571-4229
Mailing Address - Fax:
Practice Address - Street 1:1 ELSIE ST
Practice Address - Street 2:
Practice Address - City:ROME
Practice Address - State:NY
Practice Address - Zip Code:13440-2556
Practice Address - Country:US
Practice Address - Phone:315-339-2220
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-08-28
Last Update Date:2013-08-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY012476-1225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist