Provider Demographics
NPI:1376735969
Name:WALIN, ELAINE MARLENE
Entity Type:Individual
Prefix:
First Name:ELAINE
Middle Name:MARLENE
Last Name:WALIN
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 1:9219 BARRINGTON TER
Mailing Address - Street 2:
Mailing Address - City:BROOKLYN PARK
Mailing Address - State:MN
Mailing Address - Zip Code:55443-1718
Mailing Address - Country:US
Mailing Address - Phone:218-341-1532
Mailing Address - Fax:
Practice Address - Street 1:1080 E STERNBERG RD
Practice Address - Street 2:
Practice Address - City:MUSKEGON
Practice Address - State:MI
Practice Address - Zip Code:49444-8796
Practice Address - Country:US
Practice Address - Phone:231-799-2200
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-08-16
Last Update Date:2007-08-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN7911225100000X
MI5501013451225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist