1043503147 NPI number — KATIE BROOKE WALTERS MOT,OTR/L

Table of content: KATIE BROOKE WALTERS MOT,OTR/L (NPI 1043503147)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1043503147 NPI number — KATIE BROOKE WALTERS MOT,OTR/L

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
WALTERS
Provider First Name:
KATIE
Provider Middle Name:
BROOKE
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
MOT,OTR/L
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1043503147
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
05/23/2011
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
2230 WOODBURY PIKE
Provider Second Line Business Mailing Address:
SUITE 1
Provider Business Mailing Address City Name:
LOYSBURG
Provider Business Mailing Address State Name:
PA
Provider Business Mailing Address Postal Code:
16659-9506
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
814-766-2295
Provider Business Mailing Address Fax Number:
814-766-2642

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2230 WOODBURY PIKE
Provider Second Line Business Practice Location Address:
SUITE 1
Provider Business Practice Location Address City Name:
LOYSBURG
Provider Business Practice Location Address State Name:
PA
Provider Business Practice Location Address Postal Code:
16659-9506
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
814-766-2295
Provider Business Practice Location Address Fax Number:
814-766-2642
Provider Enumeration Date:
05/23/2011

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 225XP0019X , with the licence number:  OC011505 , registered in the state of PA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)





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