Provider Demographics
NPI:1811006562
Name:WALTER, ALICE D (PT)
Entity Type:Individual
Prefix:
First Name:ALICE
Middle Name:D
Last Name:WALTER
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12310 INTERLAAKEN DR SW APT L
Mailing Address - Street 2:
Mailing Address - City:TACOMA
Mailing Address - State:WA
Mailing Address - Zip Code:98498-5402
Mailing Address - Country:US
Mailing Address - Phone:253-381-3431
Mailing Address - Fax:253-445-1250
Practice Address - Street 1:6007 119TH AVE E
Practice Address - Street 2:
Practice Address - City:PUYALLUP
Practice Address - State:WA
Practice Address - Zip Code:98372-2830
Practice Address - Country:US
Practice Address - Phone:253-848-9769
Practice Address - Fax:253-445-1250
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-29
Last Update Date:2012-02-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAPT00000660174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA0191258OtherDEPARTMENT OF LABOR AND INDUSTRIES
WAG8800758Medicare ID - Type Unspecified
WAQ07671Medicare UPIN