Provider Demographics
NPI:1861039562
Name:WALKER, MARIAH DEIRDRE (PTA)
Entity Type:Individual
Prefix:
First Name:MARIAH
Middle Name:DEIRDRE
Last Name:WALKER
Suffix:
Gender:F
Credentials:PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1745 HORTON DR
Mailing Address - Street 2:
Mailing Address - City:ORANGE PARK
Mailing Address - State:FL
Mailing Address - Zip Code:32073-2756
Mailing Address - Country:US
Mailing Address - Phone:720-397-0797
Mailing Address - Fax:
Practice Address - Street 1:8000 ARLINGTON CIR
Practice Address - Street 2:
Practice Address - City:NAPLES
Practice Address - State:FL
Practice Address - Zip Code:34113-3205
Practice Address - Country:US
Practice Address - Phone:239-307-3061
Practice Address - Fax:847-730-2908
Is Sole Proprietor?:Yes
Enumeration Date:2019-12-02
Last Update Date:2019-12-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPTA29811225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant