Provider Demographics
NPI:1699598870
Name:WEAKLEY, WALTER MARION III (LMT, MMT)
Entity type:Individual
Prefix:
First Name:WALTER
Middle Name:MARION
Last Name:WEAKLEY
Suffix:III
Gender:M
Credentials:LMT, MMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1700 BRITT RD
Mailing Address - Street 2:
Mailing Address - City:CANTONMENT
Mailing Address - State:FL
Mailing Address - Zip Code:32533-4595
Mailing Address - Country:US
Mailing Address - Phone:850-417-5619
Mailing Address - Fax:
Practice Address - Street 1:744 E BURGESS RD STE A101
Practice Address - Street 2:
Practice Address - City:PENSACOLA
Practice Address - State:FL
Practice Address - Zip Code:32504-6360
Practice Address - Country:US
Practice Address - Phone:850-417-5619
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-11-05
Last Update Date:2024-11-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLMA94847225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist