Provider Demographics
NPI:1164382578
Name:WALTER, TIA
Entity type:Individual
Prefix:
First Name:TIA
Middle Name:
Last Name:WALTER
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2500 VANTAGE DR APT 367
Mailing Address - Street 2:
Mailing Address - City:WOODBRIDGE
Mailing Address - State:VA
Mailing Address - Zip Code:22191-1567
Mailing Address - Country:US
Mailing Address - Phone:571-659-8377
Mailing Address - Fax:
Practice Address - Street 1:14605 POTOMAC BRANCH DR STE 300
Practice Address - Street 2:
Practice Address - City:WOODBRIDGE
Practice Address - State:VA
Practice Address - Zip Code:22191-3337
Practice Address - Country:US
Practice Address - Phone:703-490-1330
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2025-11-17
Last Update Date:2025-11-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant