Provider Demographics
NPI:1497346605
Name:HEIDER-WALSH, KELLY
Entity Type:Individual
Prefix:
First Name:KELLY
Middle Name:
Last Name:HEIDER-WALSH
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 1:9 WILLOW ST
Mailing Address - Street 2:
Mailing Address - City:SELDEN
Mailing Address - State:NY
Mailing Address - Zip Code:11784-2807
Mailing Address - Country:US
Mailing Address - Phone:516-983-9845
Mailing Address - Fax:
Practice Address - Street 1:1014 GRAND BLVD STE 5
Practice Address - Street 2:
Practice Address - City:DEER PARK
Practice Address - State:NY
Practice Address - Zip Code:11729-5782
Practice Address - Country:US
Practice Address - Phone:631-243-1765
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-01-30
Last Update Date:2021-01-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist