Most Relevant Information
Provider Data
| NPI Number: | 1003490228 |
| Provider Name: | RAYMOND M WALLACE COTA/L |
| Entity Type: | Individual |
| Taxonomy Code: | 224Z00000X |
| Specialty: | Occupational Therapy Assistant |
| License Number: | 569 |
Most Important Dates
| Enumeration Date: | 05/12/2021 |
| Last Updated: | 05/12/2021 |
Provider Practice Location
6956 S 310TH EAST AVE
BROKEN ARROW
OK
740145491
Practice Location Phone/Fax
| Phone: | 9182308099 |
| Fax: |
Provider Mailing Location
6956 S 310TH EAST AVE
BROKEN ARROW
OK
740145491
Provider Mailing Phone/Fax
| Phone: | 9182308099 |
| Fax: |