Provider Demographics
NPI:1831121839
Name:WALTERS, MICHELLE LYNN (MPT)
Entity Type:Individual
Prefix:MISS
First Name:MICHELLE
Middle Name:LYNN
Last Name:WALTERS
Suffix:
Gender:F
Credentials:MPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:915 HARGER RD
Mailing Address - Street 2:SUITE 101
Mailing Address - City:OAK BROOK
Mailing Address - State:IL
Mailing Address - Zip Code:60523-1497
Mailing Address - Country:US
Mailing Address - Phone:773-984-9428
Mailing Address - Fax:
Practice Address - Street 1:915 HARGER RD
Practice Address - Street 2:SUITE 101
Practice Address - City:OAK BROOK
Practice Address - State:IL
Practice Address - Zip Code:60523-1497
Practice Address - Country:US
Practice Address - Phone:773-984-9428
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-07
Last Update Date:2009-10-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA32702225100000X
IL070015511225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist