Provider Demographics
NPI:1427425347
Name:WALTERS, BRIAN DOUGLAS (LMT)
Entity type:Individual
Prefix:
First Name:BRIAN
Middle Name:DOUGLAS
Last Name:WALTERS
Suffix:
Gender:M
Credentials:LMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4018 SUE LN
Mailing Address - Street 2:
Mailing Address - City:DECATUR
Mailing Address - State:GA
Mailing Address - Zip Code:30035-1075
Mailing Address - Country:US
Mailing Address - Phone:404-438-4477
Mailing Address - Fax:800-975-1805
Practice Address - Street 1:2045 ROCKBRIDGE RD
Practice Address - Street 2:
Practice Address - City:STONE MOUNTAIN
Practice Address - State:GA
Practice Address - Zip Code:30087-3551
Practice Address - Country:US
Practice Address - Phone:678-883-2873
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-08-26
Last Update Date:2015-08-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAMT007445225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist