Provider Demographics
NPI:1538328539
Name:WALLSH, IAN K (PT)
Entity Type:Individual
Prefix:MR
First Name:IAN
Middle Name:K
Last Name:WALLSH
Suffix:
Gender:M
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:704 NORTH IRENA AVE UNIT B
Mailing Address - Street 2:
Mailing Address - City:REDONDO BEACH
Mailing Address - State:CA
Mailing Address - Zip Code:90277-2217
Mailing Address - Country:US
Mailing Address - Phone:310-379-2926
Mailing Address - Fax:
Practice Address - Street 1:704 N IRENA AVE UNIT B
Practice Address - Street 2:
Practice Address - City:REDONDO BEACH
Practice Address - State:CA
Practice Address - Zip Code:90277-2217
Practice Address - Country:US
Practice Address - Phone:310-379-2926
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-06-04
Last Update Date:2019-07-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA34642225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist