Provider Demographics
NPI:1003148289
Name:WALLER OCCUPATIONAL THERAPY AND CONSULTING, LLC
Entity Type:Organization
Organization Name:WALLER OCCUPATIONAL THERAPY AND CONSULTING, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MS
Authorized Official - First Name:EULANDA
Authorized Official - Middle Name:LARA
Authorized Official - Last Name:WALLER
Authorized Official - Suffix:
Authorized Official - Credentials:OTR/L
Authorized Official - Phone:478-318-2313
Mailing Address - Street 1:315 CHRISTINA CT
Mailing Address - Street 2:
Mailing Address - City:MACON
Mailing Address - State:GA
Mailing Address - Zip Code:31217-4528
Mailing Address - Country:US
Mailing Address - Phone:478-755-0335
Mailing Address - Fax:478-755-0335
Practice Address - Street 1:315 CHRISTINA CT
Practice Address - Street 2:
Practice Address - City:MACON
Practice Address - State:GA
Practice Address - Zip Code:31217-4528
Practice Address - Country:US
Practice Address - Phone:478-755-0335
Practice Address - Fax:478-755-0335
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-02-12
Last Update Date:2010-02-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAOT003394225X00000X, 225XE0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational TherapistGroup - Multi-Specialty
No225XE0001XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational TherapistEnvironmental ModificationGroup - Multi-Specialty