Provider Demographics
NPI:1982628970
Name:WALLER, DIANE (RKT)
Entity Type:Individual
Prefix:MRS
First Name:DIANE
Middle Name:
Last Name:WALLER
Suffix:
Gender:F
Credentials:RKT
Other - Prefix:
Other - First Name:DIANE
Other - Middle Name:
Other - Last Name:WALLER
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:RKT
Mailing Address - Street 1:4500 S LANCASTER RD
Mailing Address - Street 2:
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75216-7167
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:4500 S LANCASTER RD
Practice Address - Street 2:
Practice Address - City:DALLAS
Practice Address - State:TX
Practice Address - Zip Code:75216-7167
Practice Address - Country:US
Practice Address - Phone:817-385-5949
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-07-26
Last Update Date:2014-10-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
1383226300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes226300000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersKinesiotherapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
1383OtherCOPSKT