Provider Demographics
NPI:1366518771
Name:WALLACE, NOREEN (OTR L)
Entity type:Individual
Prefix:
First Name:NOREEN
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:PO BOX 397
Mailing Address - Street 2:
Mailing Address - City:WOODSTOCK
Mailing Address - State:CT
Mailing Address - Zip Code:06281
Mailing Address - Country:US
Mailing Address - Phone:860-963-0712
Mailing Address - Fax:860-963-0712
Practice Address - Street 1:602 RTE 169
Practice Address - Street 2:
Practice Address - City:WOODSTOCK
Practice Address - State:CT
Practice Address - Zip Code:06281
Practice Address - Country:US
Practice Address - Phone:860-963-0712
Practice Address - Fax:860-963-0712
Is Sole Proprietor?:No
Enumeration Date:2006-11-28
Last Update Date:2011-09-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT00042225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
2V8290OtherORTHONET
747741OtherCONNECTICARE
P815837OtherOXFORD
130000442CT01OtherANTHEM BLUE CROSS BLUE SH
2957257OtherAETNA
OV7803OtherHEALTHNET
747741OtherCONNECTICARE