Provider Demographics
NPI:1114468691
Name:WALSH, MICHAEL (DPT, ATC)
Entity Type:Individual
Prefix:
First Name:MICHAEL
Middle Name:
Last Name:WALSH
Suffix:
Gender:M
Credentials:DPT, ATC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:116 BROWNSVILLE ST NE
Mailing Address - Street 2:
Mailing Address - City:PRESTON
Mailing Address - State:MN
Mailing Address - Zip Code:55965-1127
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:3100 19TH ST NW STE 200
Practice Address - Street 2:
Practice Address - City:ROCHESTER
Practice Address - State:MN
Practice Address - Zip Code:55901-6606
Practice Address - Country:US
Practice Address - Phone:507-322-3460
Practice Address - Fax:507-322-3450
Is Sole Proprietor?:No
Enumeration Date:2017-03-16
Last Update Date:2021-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
2255A2300X, 390200000X
MN12299225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
No2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program