Individual
MRS. MARY ERICSON WALLER
Active
Sole proprietor
No
Provider details
NPI number
Gender
F
Credential
OT
Contact information
Practice address
2720 SUNSET BLVD, WEST COLUMBIA, SC 29169-4810
(803) 791-2000
Mailing address
2720 SUNSET BLVD, WEST COLUMBIA, SC 29169-4810
(803) 791-2000
Taxonomy
Speciality
Code
Description
License number
State
225X00000X
Occupational Therapist
Primary
640
SC
Other
Enumeration date
10/17/2012
Last updated
10/17/2012
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