Provider Demographics
NPI:1245398023
Name:WALLER, JUDITH I (PT)
Entity Type:Individual
Prefix:MS
First Name:JUDITH
Middle Name:I
Last Name:WALLER
Suffix:
Gender:F
Credentials:PT
Other - Prefix:MS
Other - First Name:JUDE
Other - Middle Name:
Other - Last Name:WALLER
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:PHYSICAL THERAPIST
Mailing Address - Street 1:330 SW 43RD ST
Mailing Address - Street 2:SUITE K, PMB 117
Mailing Address - City:RENTON
Mailing Address - State:WA
Mailing Address - Zip Code:98057-4900
Mailing Address - Country:US
Mailing Address - Phone:206-439-0499
Mailing Address - Fax:206-244-3783
Practice Address - Street 1:981 POWELL AVE SW
Practice Address - Street 2:130
Practice Address - City:RENTON
Practice Address - State:WA
Practice Address - Zip Code:98057-2990
Practice Address - Country:US
Practice Address - Phone:206-439-0449
Practice Address - Fax:206-244-3783
Is Sole Proprietor?:No
Enumeration Date:2006-12-05
Last Update Date:2014-01-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAPT00002638225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist