Provider Demographics
NPI:1063207629
Name:WALLER, KARLY KRODELL (OTD, OTR/L)
Entity type:Individual
Prefix:
First Name:KARLY
Middle Name:KRODELL
Last Name:WALLER
Suffix:
Gender:
Credentials:OTD, OTR/L
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:20561 SPRINGSTON FORD RD
Mailing Address - Street 2:
Mailing Address - City:ELKINS
Mailing Address - State:AR
Mailing Address - Zip Code:72727-3577
Mailing Address - Country:US
Mailing Address - Phone:479-445-2151
Mailing Address - Fax:
Practice Address - Street 1:259 RIVER RIDGE WAY
Practice Address - Street 2:
Practice Address - City:SWANSEA
Practice Address - State:SC
Practice Address - Zip Code:29160-8287
Practice Address - Country:US
Practice Address - Phone:479-445-2151
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2025-04-14
Last Update Date:2025-04-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC7542225XP0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225XP0200XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational TherapistPediatrics