Basic Information
| Provider Information | |||||||||
| NPI: | 1003143546 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | WALSH | ||||||||
| FirstName: | KRISTEN | ||||||||
| MiddleName: | K | ||||||||
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| OtherLastName: | UNGUREAN | ||||||||
| OtherFirstName: | KRISTEN | ||||||||
| OtherMiddleName: | K | ||||||||
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| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 465 42ND AVE | ||||||||
| Address2: | SUITE 145 | ||||||||
| City: | EAST MOLINE | ||||||||
| State: | IL | ||||||||
| PostalCode: | 612444044 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3097793190 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 465 42ND AVE | ||||||||
| Address2: | SUITE 145 | ||||||||
| City: | EAST MOLINE | ||||||||
| State: | IL | ||||||||
| PostalCode: | 612444044 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3097793190 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/04/2009 | ||||||||
| LastUpdateDate: | 11/04/2009 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225X00000X | 056003977 | IL | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Occupational Therapist |
No ID Information.