Provider Demographics
NPI:1679965529
Name:WALTERS, WILSON CHRISTOPHER (COTA)
Entity Type:Individual
Prefix:MR
First Name:WILSON
Middle Name:CHRISTOPHER
Last Name:WALTERS
Suffix:
Gender:M
Credentials:COTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:915 MIDDLE RIVER DR
Mailing Address - Street 2:
Mailing Address - City:FORT LAUDERDALE
Mailing Address - State:FL
Mailing Address - Zip Code:33304-3544
Mailing Address - Country:US
Mailing Address - Phone:954-549-6125
Mailing Address - Fax:
Practice Address - Street 1:6530 THOMAS ST
Practice Address - Street 2:
Practice Address - City:HOLLYWOOD
Practice Address - State:FL
Practice Address - Zip Code:33024-4037
Practice Address - Country:US
Practice Address - Phone:954-549-6125
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-03-02
Last Update Date:2015-03-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLOTA14167224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant