Provider Demographics
NPI:1518197680
Name:WALSH, KATHLEEN ELIZABETH
Entity Type:Individual
Prefix:MISS
First Name:KATHLEEN
Middle Name:ELIZABETH
Last Name:WALSH
Suffix:
Gender:F
Credentials:
Other - Prefix:MRS
Other - First Name:KATHLEEN
Other - Middle Name:ELIZABETH
Other - Last Name:MARTIN
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:LAC, MSOM
Mailing Address - Street 1:W340N6204 BREEZY POINT RD
Mailing Address - Street 2:
Mailing Address - City:OCONOMOWOC
Mailing Address - State:WI
Mailing Address - Zip Code:53066-5111
Mailing Address - Country:US
Mailing Address - Phone:262-853-1915
Mailing Address - Fax:
Practice Address - Street 1:W340N6204 BREEZY POINT RD
Practice Address - Street 2:
Practice Address - City:OCONOMOWOC
Practice Address - State:WI
Practice Address - Zip Code:53066-5111
Practice Address - Country:US
Practice Address - Phone:262-853-1915
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-07-22
Last Update Date:2009-07-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI552-55171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171100000XOther Service ProvidersAcupuncturist