Provider Demographics
NPI:1740640119
Name:WALTERS, ANGELA (COTA/L)
Entity type:Individual
Prefix:
First Name:ANGELA
Middle Name:
Last Name:WALTERS
Suffix:
Gender:F
Credentials:COTA/L
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3728 UPPER SALEM RD
Mailing Address - Street 2:
Mailing Address - City:METROPOLIS
Mailing Address - State:IL
Mailing Address - Zip Code:62960-3091
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:142 STUART NELSON PARK RD
Practice Address - Street 2:
Practice Address - City:PADUCAH
Practice Address - State:KY
Practice Address - Zip Code:42001-9678
Practice Address - Country:US
Practice Address - Phone:270-442-9502
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-02-29
Last Update Date:2017-06-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY134992224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant