Provider Demographics
NPI:1073759619
Name:WALLER, EULANDA LARA (OTR/L)
Entity Type:Individual
Prefix:MS
First Name:EULANDA
Middle Name:LARA
Last Name:WALLER
Suffix:
Gender:F
Credentials:OTR/L
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:315 CHRISTINA CT
Mailing Address - Street 2:
Mailing Address - City:MACON
Mailing Address - State:GA
Mailing Address - Zip Code:31217-1331
Mailing Address - Country:US
Mailing Address - Phone:478-318-2313
Mailing Address - Fax:
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:478-318-2313
Practice Address - Fax:478-755-0335
Is Sole Proprietor?:Yes
Enumeration Date:2009-01-04
Last Update Date:2013-02-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAOT003394225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA874780070AMedicaid