Healthcare Provider Details

I. General information

NPI: 1487240677
Provider Name (Legal Business Name): STEPHEN WALTER
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/12/2020
Last Update Date: 12/12/2020
Certification Date: 12/12/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3710 OLENTANGY RIVER RD
COLUMBUS OH
43214-3426
US

IV. Provider business mailing address

3008 NEIL AVE APT 71C
COLUMBUS OH
43202-2070
US

V. Phone/Fax

Practice location:
  • Phone: 614-457-1100
  • Fax:
Mailing address:
  • Phone: 440-925-5559
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225200000X
TaxonomyPhysical Therapy Assistant
License NumberPTA011932
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: