Basic Information
| Provider Information | |||||||||
| NPI: | 1114105855 | ||||||||
| EntityType: | 1 | ||||||||
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| LastName: | WALLER | ||||||||
| FirstName: | HEATHER | ||||||||
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| Mailing Information | |||||||||
| Address1: | 111 NATURE WALK PKWY | ||||||||
| Address2: | SUITE 101 | ||||||||
| City: | ST AUGUSTINE | ||||||||
| State: | FL | ||||||||
| PostalCode: | 320925073 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9042307761 | ||||||||
| FaxNumber: | 9042307763 | ||||||||
| Practice Location | |||||||||
| Address1: | 111 NATURE WALK PKWY | ||||||||
| Address2: | SUITE 101 | ||||||||
| City: | ST AUGUSTINE | ||||||||
| State: | FL | ||||||||
| PostalCode: | 320925073 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9042307761 | ||||||||
| FaxNumber: | 9042307763 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/05/2008 | ||||||||
| LastUpdateDate: | 02/05/2008 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 235Z00000X | SA9324 | FL | Y | Speech, Language and Hearing Service Providers | Speech-Language Pathologist |
No ID Information.