Provider Demographics
NPI:1659926301
Name:WALLER, CASEY (PT, DPT)
Entity Type:Individual
Prefix:DR
First Name:CASEY
Middle Name:
Last Name:WALLER
Suffix:
Gender:M
Credentials:PT, DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1084 N. EL CAMINO REAL, B-351
Mailing Address - Street 2:
Mailing Address - City:CARLSBAD
Mailing Address - State:CA
Mailing Address - Zip Code:92010-1334
Mailing Address - Country:US
Mailing Address - Phone:760-918-9200
Mailing Address - Fax:
Practice Address - Street 1:2719 LOKER AVE W STE A
Practice Address - Street 2:
Practice Address - City:CARLSBAD
Practice Address - State:CA
Practice Address - Zip Code:92010-6679
Practice Address - Country:US
Practice Address - Phone:760-918-9200
Practice Address - Fax:760-918-9203
Is Sole Proprietor?:No
Enumeration Date:2019-08-08
Last Update Date:2019-08-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA296993225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA296993OtherCA PHYSICAL THERAPY BOARD