Provider Demographics
NPI:1083986939
Name:BURNETT, WALTER MAGILL (PTA)
Entity Type:Individual
Prefix:MR
First Name:WALTER
Middle Name:MAGILL
Last Name:BURNETT
Suffix:
Gender:M
Credentials:PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1519 TAYLOR ST
Mailing Address - Street 2:
Mailing Address - City:COLUMBIA
Mailing Address - State:SC
Mailing Address - Zip Code:29201-2918
Mailing Address - Country:US
Mailing Address - Phone:803-779-8327
Mailing Address - Fax:803-799-3603
Practice Address - Street 1:1519 TAYLOR ST
Practice Address - Street 2:
Practice Address - City:COLUMBIA
Practice Address - State:SC
Practice Address - Zip Code:29201-2918
Practice Address - Country:US
Practice Address - Phone:803-779-8327
Practice Address - Fax:803-799-3603
Is Sole Proprietor?:No
Enumeration Date:2012-02-07
Last Update Date:2012-02-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC2734225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
2734OtherSC BOARD OF PHYSICAL THERAPY EXAMINERS