Provider Demographics
NPI:1295365542
Name:WALSH, SUSAN (DN, MED, ATCL)
Entity Type:Individual
Prefix:
First Name:SUSAN
Middle Name:
Last Name:WALSH
Suffix:
Gender:F
Credentials:DN, MED, ATCL
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2323 N SHEFFIELD AVE
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60614-3290
Mailing Address - Country:US
Mailing Address - Phone:773-325-4473
Mailing Address - Fax:
Practice Address - Street 1:2323 N SHEFFIELD AVE
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60614-3290
Practice Address - Country:US
Practice Address - Phone:773-325-4473
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-01-24
Last Update Date:2020-01-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL096.0005232255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic TrainerGroup - Single Specialty