Provider Demographics
NPI:1982004628
Name:WALKER, THAD (ATC,)
Entity Type:Individual
Prefix:
First Name:THAD
Middle Name:
Last Name:WALKER
Suffix:
Gender:M
Credentials:ATC,
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3007 WOLF CREEK LN
Mailing Address - Street 2:
Mailing Address - City:NORMAL
Mailing Address - State:IL
Mailing Address - Zip Code:61761-9631
Mailing Address - Country:US
Mailing Address - Phone:309-846-2404
Mailing Address - Fax:
Practice Address - Street 1:3007 WOLF CREEK LN
Practice Address - Street 2:
Practice Address - City:NORMAL
Practice Address - State:IL
Practice Address - Zip Code:61761-9631
Practice Address - Country:US
Practice Address - Phone:309-846-2404
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-08-29
Last Update Date:2014-08-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL0960025622255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer