Provider Demographics
NPI:1649345414
Name:WALTER, CHERYL K (RPT)
Entity type:Individual
Prefix:MRS
First Name:CHERYL
Middle Name:K
Last Name:WALTER
Suffix:
Gender:F
Credentials:RPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:414 W MAIN ST
Mailing Address - Street 2:
Mailing Address - City:LAKE CITY
Mailing Address - State:SC
Mailing Address - Zip Code:29560-2318
Mailing Address - Country:US
Mailing Address - Phone:843-374-7378
Mailing Address - Fax:843-374-7379
Practice Address - Street 1:414 W MAIN ST
Practice Address - Street 2:
Practice Address - City:LAKE CITY
Practice Address - State:SC
Practice Address - Zip Code:29560-2318
Practice Address - Country:US
Practice Address - Phone:843-374-7378
Practice Address - Fax:843-374-7379
Is Sole Proprietor?:No
Enumeration Date:2006-11-21
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC1089225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
SC1089OtherLICENSE NUMBER
SCTH0066Medicaid