Provider Demographics
NPI:1386119717
Name:WALTOWER, CRYSTAL DAWN (LOTR)
Entity type:Individual
Prefix:MRS
First Name:CRYSTAL
Middle Name:DAWN
Last Name:WALTOWER
Suffix:
Gender:F
Credentials:LOTR
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:150 GLADNEY FARM RD
Mailing Address - Street 2:
Mailing Address - City:HOMER
Mailing Address - State:LA
Mailing Address - Zip Code:71040-5009
Mailing Address - Country:US
Mailing Address - Phone:337-427-0160
Mailing Address - Fax:
Practice Address - Street 1:403 E FLOURNOY LUCAS RD
Practice Address - Street 2:
Practice Address - City:SHREVEPORT
Practice Address - State:LA
Practice Address - Zip Code:71115-3906
Practice Address - Country:US
Practice Address - Phone:318-798-3500
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-10-12
Last Update Date:2018-10-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA200690225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist