Provider Demographics
NPI:1265866081
Name:WALSH, NICCOL R (MASSAGE THERAPIST)
Entity Type:Individual
Prefix:
First Name:NICCOL
Middle Name:R
Last Name:WALSH
Suffix:
Gender:F
Credentials:MASSAGE THERAPIST
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:19817 N 46TH DR
Mailing Address - Street 2:
Mailing Address - City:GLENDALE
Mailing Address - State:AZ
Mailing Address - Zip Code:85308-7325
Mailing Address - Country:US
Mailing Address - Phone:602-367-2167
Mailing Address - Fax:
Practice Address - Street 1:19817 N 46TH DR
Practice Address - Street 2:
Practice Address - City:GLENDALE
Practice Address - State:AZ
Practice Address - Zip Code:85308-7325
Practice Address - Country:US
Practice Address - Phone:602-367-2167
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-08-28
Last Update Date:2019-08-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZMT17847225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist