Provider Demographics
NPI:1811380801
Name:WALTS, BRIDGET ELIZABETH (LMT)
Entity Type:Individual
Prefix:
First Name:BRIDGET
Middle Name:ELIZABETH
Last Name:WALTS
Suffix:
Gender:F
Credentials:LMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:885 COUNTY ROUTE 57
Mailing Address - Street 2:
Mailing Address - City:PHOENIX
Mailing Address - State:NY
Mailing Address - Zip Code:13135-2197
Mailing Address - Country:US
Mailing Address - Phone:315-420-1634
Mailing Address - Fax:
Practice Address - Street 1:885 COUNTY ROUTE 57
Practice Address - Street 2:
Practice Address - City:PHOENIX
Practice Address - State:NY
Practice Address - Zip Code:13135-2197
Practice Address - Country:US
Practice Address - Phone:315-420-1634
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-03-15
Last Update Date:2015-03-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY27 028627225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist