Provider Demographics
NPI:1255143368
Name:WALLER, EMILY (OTR/L)
Entity type:Individual
Prefix:
First Name:EMILY
Middle Name:
Last Name:WALLER
Suffix:
Gender:
Credentials:OTR/L
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:806 FAYETTEVILLE RD SE
Mailing Address - Street 2:
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30316-2913
Mailing Address - Country:US
Mailing Address - Phone:484-678-9740
Mailing Address - Fax:
Practice Address - Street 1:739 W PEACHTREE ST NW
Practice Address - Street 2:
Practice Address - City:ATLANTA
Practice Address - State:GA
Practice Address - Zip Code:30308
Practice Address - Country:US
Practice Address - Phone:404-875-9011
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2025-01-24
Last Update Date:2025-03-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAOT009383225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist