Provider Demographics
NPI:1205407533
Name:WALLS, KRYSTAL (MSOTR)
Entity Type:Individual
Prefix:
First Name:KRYSTAL
Middle Name:
Last Name:WALLS
Suffix:
Gender:F
Credentials:MSOTR
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:324 N COUNTY ROAD 325 W
Mailing Address - Street 2:
Mailing Address - City:DANVILLE
Mailing Address - State:IN
Mailing Address - Zip Code:46122-8854
Mailing Address - Country:US
Mailing Address - Phone:317-446-7840
Mailing Address - Fax:
Practice Address - Street 1:5865 SUGAR LN
Practice Address - Street 2:
Practice Address - City:PLAINFIELD
Practice Address - State:IN
Practice Address - Zip Code:46168-8328
Practice Address - Country:US
Practice Address - Phone:317-839-7900
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-07-07
Last Update Date:2021-07-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN31004676A225XP0019X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225XP0019XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational TherapistPhysical Rehabilitation