Provider Demographics
NPI:1588247373
Name:WALLS, GEORGE THOMAS III
Entity type:Individual
Prefix:MR
First Name:GEORGE
Middle Name:THOMAS
Last Name:WALLS
Suffix:III
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7600 AUTUMN PARK WAY
Mailing Address - Street 2:
Mailing Address - City:MECHANICSVILLE
Mailing Address - State:VA
Mailing Address - Zip Code:23116-3868
Mailing Address - Country:US
Mailing Address - Phone:804-730-0009
Mailing Address - Fax:
Practice Address - Street 1:7600 AUTUMN PARK WAY
Practice Address - Street 2:
Practice Address - City:MECHANICSVILLE
Practice Address - State:VA
Practice Address - Zip Code:23116-3868
Practice Address - Country:US
Practice Address - Phone:804-730-0009
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-04-30
Last Update Date:2021-04-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
225XE0001X
VA0131000254224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant
No225XE0001XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational TherapistEnvironmental Modification