Provider Demographics
NPI:1659616746
Name:WALTERS, ANIQUE (DPT)
Entity Type:Individual
Prefix:
First Name:ANIQUE
Middle Name:
Last Name:WALTERS
Suffix:
Gender:F
Credentials:DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1821 WILSHIRE BLVD
Mailing Address - Street 2:SUITE 400
Mailing Address - City:SANTA MONICA
Mailing Address - State:CA
Mailing Address - Zip Code:90403-5618
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1821 WILSHIRE BLVD
Practice Address - Street 2:SUITE 400
Practice Address - City:SANTA MONICA
Practice Address - State:CA
Practice Address - Zip Code:90403-5618
Practice Address - Country:US
Practice Address - Phone:310-828-2188
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-11-30
Last Update Date:2013-01-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA39570225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist