Healthcare Provider Details

I. General information

NPI: 1265939664
Provider Name (Legal Business Name): THERESA WALTER PT
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/11/2018
Last Update Date: 02/24/2021
Certification Date: 02/24/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

107 SCHOOLCREST AVE
CLARE MI
48617-1145
US

IV. Provider business mailing address

2600 N SAGINAW RD STE C
MIDLAND MI
48640-2690
US

V. Phone/Fax

Practice location:
  • Phone: 989-386-9170
  • Fax: 989-386-9220
Mailing address:
  • Phone: 989-386-9170
  • Fax: 989-386-9220

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2251G0304X
TaxonomyGeriatric Physical Therapist
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number5501011412
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: