Provider Demographics
NPI:1407324825
Name:WALTER, TAYLOR MARIE (DPT)
Entity Type:Individual
Prefix:
First Name:TAYLOR
Middle Name:MARIE
Last Name:WALTER
Suffix:
Gender:F
Credentials:DPT
Other - Prefix:
Other - First Name:TAYLOR
Other - Middle Name:MARIE
Other - Last Name:WILLE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:DPT
Mailing Address - Street 1:1513 COLWYN DR
Mailing Address - Street 2:
Mailing Address - City:CANTONMENT
Mailing Address - State:FL
Mailing Address - Zip Code:32533-6811
Mailing Address - Country:US
Mailing Address - Phone:904-537-4312
Mailing Address - Fax:
Practice Address - Street 1:13223 BLACK MOUNTAIN RD # 1358
Practice Address - Street 2:
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92129-2698
Practice Address - Country:US
Practice Address - Phone:858-753-5082
Practice Address - Fax:858-800-2523
Is Sole Proprietor?:Yes
Enumeration Date:2018-11-03
Last Update Date:2020-04-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPT341332251P0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
No2251P0200XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistPediatrics