Provider Demographics
NPI:1295865509
Name:WALKER, PHYLLIS D (PT)
Entity Type:Individual
Prefix:
First Name:PHYLLIS
Middle Name:D
Last Name:WALKER
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:137 FRONT ST
Mailing Address - Street 2:
Mailing Address - City:DEPOSIT
Mailing Address - State:NY
Mailing Address - Zip Code:13754-1128
Mailing Address - Country:US
Mailing Address - Phone:607-467-5858
Mailing Address - Fax:607-467-5655
Practice Address - Street 1:1621 HIGHWAY 17 N
Practice Address - Street 2:
Practice Address - City:NORTH MYRTLE BEACH
Practice Address - State:SC
Practice Address - Zip Code:29582-2229
Practice Address - Country:US
Practice Address - Phone:843-353-3460
Practice Address - Fax:843-353-3461
Is Sole Proprietor?:No
Enumeration Date:2007-03-06
Last Update Date:2022-08-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY0075661225100000X
SC11392225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NYP00471498OtherRAIL ROAD MEDICARE
NY11226693OtherCAQH
NYBB9838Medicare PIN