Provider Demographics
NPI:1962975979
Name:MATLOCK, WALTER SCOTT (PTA)
Entity type:Individual
Prefix:
First Name:WALTER
Middle Name:SCOTT
Last Name:MATLOCK
Suffix:
Gender:M
Credentials:PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:19395 FORK CREEK RD.
Mailing Address - Street 2:
Mailing Address - City:PHILADELPHIA
Mailing Address - State:TN
Mailing Address - Zip Code:37846
Mailing Address - Country:US
Mailing Address - Phone:865-414-0851
Mailing Address - Fax:
Practice Address - Street 1:520 OLD HIGHWAY 68
Practice Address - Street 2:
Practice Address - City:SWEETWATER
Practice Address - State:TN
Practice Address - Zip Code:37874-6258
Practice Address - Country:US
Practice Address - Phone:423-351-1050
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-01-03
Last Update Date:2019-01-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN6842225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant