Provider Demographics
NPI:1982927133
Name:WALTHALL, THERESA M (OTR/L)
Entity type:Individual
Prefix:MRS
First Name:THERESA
Middle Name:M
Last Name:WALTHALL
Suffix:
Gender:F
Credentials:OTR/L
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8726 BRIDGEPORT AVE
Mailing Address - Street 2:
Mailing Address - City:BRENTWOOD
Mailing Address - State:MO
Mailing Address - Zip Code:63144-1808
Mailing Address - Country:US
Mailing Address - Phone:314-963-0948
Mailing Address - Fax:
Practice Address - Street 1:8726 BRIDGEPORT AVE
Practice Address - Street 2:
Practice Address - City:BRENTWOOD
Practice Address - State:MO
Practice Address - Zip Code:63144-1808
Practice Address - Country:US
Practice Address - Phone:314-963-0948
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-03-02
Last Update Date:2010-03-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO004721225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist