Provider Demographics
NPI:1063451342
Name:WALTERS, VICKIE LEONA (LPTA)
Entity Type:Individual
Prefix:MS
First Name:VICKIE
Middle Name:LEONA
Last Name:WALTERS
Suffix:
Gender:F
Credentials:LPTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1485 BROWNS BRIDGE RD
Mailing Address - Street 2:
Mailing Address - City:HATTIESBURG
Mailing Address - State:MS
Mailing Address - Zip Code:39401-8739
Mailing Address - Country:US
Mailing Address - Phone:601-434-9361
Mailing Address - Fax:
Practice Address - Street 1:433 BROAD ST
Practice Address - Street 2:
Practice Address - City:COLUMBIA
Practice Address - State:MS
Practice Address - Zip Code:39429-3038
Practice Address - Country:US
Practice Address - Phone:601-444-0030
Practice Address - Fax:
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-06-05
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MSPTA3440225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant