Provider Demographics
NPI:1164549176
Name:WALRAVEN, CATHLEEN T
Entity Type:Individual
Prefix:MS
First Name:CATHLEEN
Middle Name:T
Last Name:WALRAVEN
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 1:33 BROADWAY
Mailing Address - Street 2:LADY K LINGERIE
Mailing Address - City:DENVILLE
Mailing Address - State:NJ
Mailing Address - Zip Code:07834-2705
Mailing Address - Country:US
Mailing Address - Phone:973-627-1836
Mailing Address - Fax:973-627-7105
Practice Address - Street 1:33 BROADWAY
Practice Address - Street 2:LADY K LINGERIE
Practice Address - City:DENVILLE
Practice Address - State:NJ
Practice Address - Zip Code:07834-2705
Practice Address - Country:US
Practice Address - Phone:973-627-1836
Practice Address - Fax:973-627-7105
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-23
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225000000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOrthotic Fitter
Provider Identifiers
StateIdentifier IDID TypeIssuer
CFM00259OtherCERTIFICATION # FOR ABC
C17789OtherBOC
0550910001Medicare ID - Type Unspecified