Basic Information
| Provider Information | |||||||||
| NPI: | 1659988046 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | WALLER | ||||||||
| FirstName: | TAYLOR | ||||||||
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| Mailing Information | |||||||||
| Address1: | 3545 S NATIONAL AVE | ||||||||
| Address2: | |||||||||
| City: | SPRINGFIELD | ||||||||
| State: | MO | ||||||||
| PostalCode: | 658077310 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4172695500 | ||||||||
| FaxNumber: | 4172695508 | ||||||||
| Practice Location | |||||||||
| Address1: | 3545 S NATIONAL AVE | ||||||||
| Address2: | |||||||||
| City: | SPRINGFIELD | ||||||||
| State: | MO | ||||||||
| PostalCode: | 658077310 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4172695500 | ||||||||
| FaxNumber: | 4172695508 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/29/2020 | ||||||||
| LastUpdateDate: | 09/29/2020 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 09/29/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225X00000X | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Occupational Therapist |
No ID Information.