Provider Demographics
NPI:1629285689
Name:WALSH, KELLY ELIZABETH (MS, ATC, LAT, PES)
Entity Type:Individual
Prefix:MS
First Name:KELLY
Middle Name:ELIZABETH
Last Name:WALSH
Suffix:
Gender:F
Credentials:MS, ATC, LAT, PES
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4025 E. SKELTON CANYON CIR.
Mailing Address - Street 2:
Mailing Address - City:WESTLAKE VILLAGE
Mailing Address - State:CA
Mailing Address - Zip Code:91362-4232
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:UNIVERSITY OF CALIFORNIA SANTA BARBARA
Practice Address - Street 2:DEPARTMENT OF INTERCOLLEGIATE ATHLETICS, ICA BUILDING
Practice Address - City:SANTA BARBARA
Practice Address - State:CA
Practice Address - Zip Code:93106-5200
Practice Address - Country:US
Practice Address - Phone:805-893-3424
Practice Address - Fax:805-893-5420
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-17
Last Update Date:2008-08-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MAAH1421-AT174400000X
NATABOC 08012030174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist