Provider Demographics
NPI:1093104267
Name:WALTER, KATHERINE CORCORAN
Entity Type:Individual
Prefix:
First Name:KATHERINE
Middle Name:CORCORAN
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:PO BOX 200
Mailing Address - Street 2:
Mailing Address - City:DAYTON
Mailing Address - State:MT
Mailing Address - Zip Code:59914-0200
Mailing Address - Country:US
Mailing Address - Phone:406-206-5692
Mailing Address - Fax:
Practice Address - Street 1:837 CHIEF EDDIE HOFFMAN HWY
Practice Address - Street 2:
Practice Address - City:BETHEL
Practice Address - State:AK
Practice Address - Zip Code:99559
Practice Address - Country:US
Practice Address - Phone:907-543-3690
Practice Address - Fax:907-543-1276
Is Sole Proprietor?:Yes
Enumeration Date:2015-01-12
Last Update Date:2018-08-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MTOTPOTLIC3346225X00000X
NH2086225X00000X
MEOT2331225X00000X
AK103447225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
AK1002573Medicaid