Provider Demographics
NPI:1003143546
Name:WALSH, KRISTEN K
Entity Type:Individual
Prefix:
First Name:KRISTEN
Middle Name:K
Last Name:WALSH
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:KRISTEN
Other - Middle Name:K
Other - Last Name:UNGUREAN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:465 42ND AVE
Mailing Address - Street 2:SUITE 145
Mailing Address - City:EAST MOLINE
Mailing Address - State:IL
Mailing Address - Zip Code:61244-4044
Mailing Address - Country:US
Mailing Address - Phone:309-779-3190
Mailing Address - Fax:
Practice Address - Street 1:465 42ND AVE
Practice Address - Street 2:SUITE 145
Practice Address - City:EAST MOLINE
Practice Address - State:IL
Practice Address - Zip Code:61244-4044
Practice Address - Country:US
Practice Address - Phone:309-779-3190
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2009-11-04
Last Update Date:2009-11-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL056003977225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist