Provider Demographics
NPI:1134654031
Name:WALLDEN, KILEY (OTR/L)
Entity Type:Individual
Prefix:MS
First Name:KILEY
Middle Name:
Last Name:WALLDEN
Suffix:
Gender:F
Credentials:OTR/L
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4617 WHITE OAK AVE
Mailing Address - Street 2:
Mailing Address - City:ROCKFORD
Mailing Address - State:IL
Mailing Address - Zip Code:61114-6235
Mailing Address - Country:US
Mailing Address - Phone:815-601-7581
Mailing Address - Fax:
Practice Address - Street 1:4617 WHITE OAK AVE
Practice Address - Street 2:
Practice Address - City:ROCKFORD
Practice Address - State:IL
Practice Address - Zip Code:61114-6235
Practice Address - Country:US
Practice Address - Phone:815-601-7581
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-04-27
Last Update Date:2019-11-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL56.011160225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist