Provider Demographics
NPI:1063992188
Name:WALSH, JUSTIN KENT
Entity type:Individual
Prefix:
First Name:JUSTIN
Middle Name:KENT
Last Name:WALSH
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1900 E CALIFORNIA ST
Mailing Address - Street 2:
Mailing Address - City:GAINESVILLE
Mailing Address - State:TX
Mailing Address - Zip Code:76240-4400
Mailing Address - Country:US
Mailing Address - Phone:940-668-6263
Mailing Address - Fax:
Practice Address - Street 1:1900 E CALIFORNIA ST
Practice Address - Street 2:
Practice Address - City:GAINESVILLE
Practice Address - State:TX
Practice Address - Zip Code:76240-4400
Practice Address - Country:US
Practice Address - Phone:940-668-6263
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-08-17
Last Update Date:2018-08-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX2119949225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant