Provider Demographics
NPI:1033655998
Name:WALLER, DANIELLE (COTA/L)
Entity Type:Individual
Prefix:
First Name:DANIELLE
Middle Name:
Last Name:WALLER
Suffix:
Gender:F
Credentials:COTA/L
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3604 N 112TH TER
Mailing Address - Street 2:
Mailing Address - City:KANSAS CITY
Mailing Address - State:KS
Mailing Address - Zip Code:66109-3445
Mailing Address - Country:US
Mailing Address - Phone:316-807-2000
Mailing Address - Fax:
Practice Address - Street 1:3604 N 112TH TER
Practice Address - Street 2:
Practice Address - City:KANSAS CITY
Practice Address - State:KS
Practice Address - Zip Code:66109-3445
Practice Address - Country:US
Practice Address - Phone:316-807-2000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-01-16
Last Update Date:2017-01-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KS18-01290224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant