Provider Demographics
NPI:1164904892
Name:WALDER, KILEY M (OTR)
Entity Type:Individual
Prefix:
First Name:KILEY
Middle Name:M
Last Name:WALDER
Suffix:
Gender:F
Credentials:OTR
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2401 INDIGO LN
Mailing Address - Street 2:
Mailing Address - City:GLENVIEW
Mailing Address - State:IL
Mailing Address - Zip Code:60026-1299
Mailing Address - Country:US
Mailing Address - Phone:847-904-4717
Mailing Address - Fax:
Practice Address - Street 1:2401 INDIGO LN
Practice Address - Street 2:
Practice Address - City:GLENVIEW
Practice Address - State:IL
Practice Address - Zip Code:60026-1299
Practice Address - Country:US
Practice Address - Phone:847-904-4717
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-08-29
Last Update Date:2018-08-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL056.012388225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist