Provider Demographics
NPI:1295472884
Name:WALLER, TIARRA DANIELLE (OTR/L)
Entity type:Individual
Prefix:MRS
First Name:TIARRA
Middle Name:DANIELLE
Last Name:WALLER
Suffix:
Gender:F
Credentials:OTR/L
Other - Prefix:
Other - First Name:TIARRA
Other - Middle Name:DANIELLE
Other - Last Name:SPARKMAN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:OTR/L
Mailing Address - Street 1:21964 HIGHWAY 32
Mailing Address - Street 2:
Mailing Address - City:STE GENEVIEVE
Mailing Address - State:MO
Mailing Address - Zip Code:63670-9190
Mailing Address - Country:US
Mailing Address - Phone:573-883-9366
Mailing Address - Fax:573-883-9377
Practice Address - Street 1:21964 HIGHWAY 32
Practice Address - Street 2:
Practice Address - City:STE GENEVIEVE
Practice Address - State:MO
Practice Address - Zip Code:63670-9190
Practice Address - Country:US
Practice Address - Phone:573-883-9366
Practice Address - Fax:573-883-9377
Is Sole Proprietor?:No
Enumeration Date:2022-05-16
Last Update Date:2022-05-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2021006924225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist