Provider Demographics
NPI:1245338508
Name:WALTERS, PRISCILLA PHILIPS (PT)
Entity type:Individual
Prefix:
First Name:PRISCILLA
Middle Name:PHILIPS
Last Name:WALTERS
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 1:1845 BUSINESS CENTER DR
Mailing Address - Street 2:SUITE 127
Mailing Address - City:SAN BERNARDINO
Mailing Address - State:CA
Mailing Address - Zip Code:92408-3467
Mailing Address - Country:US
Mailing Address - Phone:909-890-9030
Mailing Address - Fax:909-890-4393
Practice Address - Street 1:10470 FOOTHILL BLVD STE 101
Practice Address - Street 2:
Practice Address - City:RANCHO CUCAMONGA
Practice Address - State:CA
Practice Address - Zip Code:91730-3754
Practice Address - Country:US
Practice Address - Phone:909-948-0411
Practice Address - Fax:909-948-0511
Is Sole Proprietor?:No
Enumeration Date:2006-09-20
Last Update Date:2019-06-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA5398225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA1245338508Medicaid
CAPT5398AMedicare PIN
CADL655YMedicare PIN