Provider Demographics
NPI:1518173376
Name:WALTI, BARBARA G (DT)
Entity Type:Individual
Prefix:MRS
First Name:BARBARA
Middle Name:G
Last Name:WALTI
Suffix:
Gender:F
Credentials:DT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:15110 W ROCKLAND RD
Mailing Address - Street 2:
Mailing Address - City:LIBERTYVILLE
Mailing Address - State:IL
Mailing Address - Zip Code:60048-9693
Mailing Address - Country:US
Mailing Address - Phone:847-680-5191
Mailing Address - Fax:847-680-5191
Practice Address - Street 1:15110 W ROCKLAND RD
Practice Address - Street 2:
Practice Address - City:LIBERTYVILLE
Practice Address - State:IL
Practice Address - Zip Code:60048-9693
Practice Address - Country:US
Practice Address - Phone:847-680-5191
Practice Address - Fax:847-680-5191
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-15
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ILBW49150998P222Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes222Q00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersDevelopmental Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL100044415-62762-01Medicaid