Provider Demographics
NPI:1568980910
Name:WALLS, KEVIN W (ATC, LAT)
Entity Type:Individual
Prefix:
First Name:KEVIN
Middle Name:W
Last Name:WALLS
Suffix:
Gender:M
Credentials:ATC, LAT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:87 GLENWOOD DR
Mailing Address - Street 2:
Mailing Address - City:LEOMINSTER
Mailing Address - State:MA
Mailing Address - Zip Code:01453-4647
Mailing Address - Country:US
Mailing Address - Phone:978-537-3806
Mailing Address - Fax:
Practice Address - Street 1:431 BOLTON ST
Practice Address - Street 2:
Practice Address - City:MARLBOROUGH
Practice Address - State:MA
Practice Address - Zip Code:01752-3950
Practice Address - Country:US
Practice Address - Phone:508-460-3500
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-09-06
Last Update Date:2017-09-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA10202255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer