Provider Demographics
NPI:1639309693
Name:WALLER, LORI (PTA)
Entity Type:Individual
Prefix:
First Name:LORI
Middle Name:
Last Name:WALLER
Suffix:
Gender:F
Credentials:PTA
Other - Prefix:
Other - First Name:LORI
Other - Middle Name:
Other - Last Name:GROTHEER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PTA
Mailing Address - Street 1:271 PYRENEES DR
Mailing Address - Street 2:
Mailing Address - City:LYMAN
Mailing Address - State:SC
Mailing Address - Zip Code:29365
Mailing Address - Country:US
Mailing Address - Phone:860-916-7637
Mailing Address - Fax:
Practice Address - Street 1:101 PARK CT
Practice Address - Street 2:
Practice Address - City:GAFFNEY
Practice Address - State:SC
Practice Address - Zip Code:29341-7021
Practice Address - Country:US
Practice Address - Phone:864-206-0006
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2009-07-23
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT000992225200000X
SC3004225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant