Provider Demographics
NPI:1881124535
Name:WALLER, JOHN WITTAKER JR (DPT)
Entity type:Individual
Prefix:
First Name:JOHN
Middle Name:WITTAKER
Last Name:WALLER
Suffix:JR
Gender:M
Credentials:DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2020 GUNBARREL RD STE 408
Mailing Address - Street 2:
Mailing Address - City:CHATTANOOGA
Mailing Address - State:TN
Mailing Address - Zip Code:37421-2663
Mailing Address - Country:US
Mailing Address - Phone:423-238-1127
Mailing Address - Fax:423-238-1277
Practice Address - Street 1:2020 GUNBARREL RD STE 408
Practice Address - Street 2:
Practice Address - City:CHATTANOOGA
Practice Address - State:TN
Practice Address - Zip Code:37421-2663
Practice Address - Country:US
Practice Address - Phone:423-648-7647
Practice Address - Fax:423-648-7648
Is Sole Proprietor?:No
Enumeration Date:2017-06-15
Last Update Date:2018-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN11240225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist