Active NPI
Bradford Anthony Wallace Jr.
- Occupational Therapy Assistant
- Newark, DE
National Provider Identifier
1609821636
On this page
Key facts
NPPES NPI Registry- Primary specialty
- Occupational Therapy Assistant
- License
- J2-0000629
- Practice address
- 130 Executive Dr
Newark, DE 19702-3349 - Phone
- (302) 292-3454
- Fax
- (302) 292-3464
- NPI assigned
- May 25, 2006
- Sex
- Male
- Sole proprietor
- No
NPPES NPI Registry
Registry information is reported by the provider to CMS and is not verified. About this source
Specialties & licenses 1
| Specialty (taxonomy) | Code | License | State | Primary |
|---|---|---|---|---|
| Occupational Therapy Assistant | 224Z00000X | J2-0000629 | DE | Primary |
Addresses
Primary practice location
130 Executive Dr
Newark, DE 19702-3349
Mailing address
2327 Pennsylvania Ave
Wilmington, DE 19806-1318
Phone (302) 571-9567
Medicare participation
Medicare enrollment files- Medicare fee-for-service enrollment
- Not listed in the public Medicare enrollment file
National Provider Directory
National Provider Directory- Medicare enrollment (NPD)
- Not enrolled
State licenses
| License | State | Type | Specialty |
|---|---|---|---|
| J2-0000629 | DE | MD | Occupational Therapy Assistant |
NPI Registry JSON
The complete NPPES record for this NPI in the NPI Registry API format.
{
"created_epoch": "1148515200000",
"enumeration_type": "NPI-1",
"last_updated_epoch": "1783900800000",
"number": "1609821636",
"addresses": [
{
"country_code": "US",
"country_name": "United States",
"address_purpose": "MAILING",
"address_type": "DOM",
"address_1": "2327 PENNSYLVANIA AVE",
"city": "WILMINGTON",
"state": "DE",
"postal_code": "198061318",
"telephone_number": "302-571-9567"
},
{
"country_code": "US",
"country_name": "United States",
"address_purpose": "LOCATION",
"address_type": "DOM",
"address_1": "130 EXECUTIVE DR",
"city": "NEWARK",
"state": "DE",
"postal_code": "197023349",
"telephone_number": "302-292-3454",
"fax_number": "302-292-3464"
}
],
"practiceLocations": [],
"basic": {
"last_name": "WALLACE",
"first_name": "BRADFORD",
"middle_name": "ANTHONY",
"name_prefix": "Mr.",
"name_suffix": "Jr.",
"sole_proprietor": "NO",
"sex": "M",
"enumeration_date": "2006-05-25",
"last_updated": "2026-07-13",
"status": "A"
},
"taxonomies": [
{
"code": "224Z00000X",
"taxonomy_group": "",
"desc": "Occupational Therapy Assistant",
"state": "DE",
"license": "J2-0000629",
"primary": true
}
],
"identifiers": [],
"endpoints": [],
"other_names": []
}Other providers in Newark, DE
Sources for this page
- NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Jul 13, 2026; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
- National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.