Provider Demographics
NPI:1417217704
Name:REYES, WALTER
Entity Type:Individual
Prefix:
First Name:WALTER
Middle Name:
Last Name:REYES
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1299 N BENEVA RD
Mailing Address - Street 2:
Mailing Address - City:SARASOTA
Mailing Address - State:FL
Mailing Address - Zip Code:34232
Mailing Address - Country:US
Mailing Address - Phone:941-951-0283
Mailing Address - Fax:941-331-4314
Practice Address - Street 1:1299 BENEVA RD
Practice Address - Street 2:
Practice Address - City:SARASOTA
Practice Address - State:FL
Practice Address - Zip Code:34232-3152
Practice Address - Country:US
Practice Address - Phone:941-951-0283
Practice Address - Fax:941-331-4314
Is Sole Proprietor?:Yes
Enumeration Date:2012-05-21
Last Update Date:2012-05-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPTA19204225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLPTA19204OtherSTATE LICENSE