Provider Demographics
NPI:1619928645
Name:WALTERS, TAMI MARIE (MOT, OTR/L)
Entity Type:Individual
Prefix:
First Name:TAMI
Middle Name:MARIE
Last Name:WALTERS
Suffix:
Gender:F
Credentials:MOT, OTR/L
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3615 SPICER DR SE
Mailing Address - Street 2:
Mailing Address - City:ALBANY
Mailing Address - State:OR
Mailing Address - Zip Code:97322-7043
Mailing Address - Country:US
Mailing Address - Phone:541-967-7551
Mailing Address - Fax:541-967-5095
Practice Address - Street 1:3615 SPICER DR SE
Practice Address - Street 2:
Practice Address - City:ALBANY
Practice Address - State:OR
Practice Address - Zip Code:97322-7043
Practice Address - Country:US
Practice Address - Phone:541-967-7551
Practice Address - Fax:541-967-5095
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-05-15
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR2261225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
ORA004OtherTRICARE ID#
ORB060404OtherPACIFICSOURCE ID#
OR158796Medicaid
OR158796Medicaid