Provider Demographics
NPI:1104376516
Name:WALK, MATTHEW (HIS)
Entity type:Individual
Prefix:MR
First Name:MATTHEW
Middle Name:
Last Name:WALK
Suffix:
Gender:M
Credentials:HIS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5553 127TH ST
Mailing Address - Street 2:
Mailing Address - City:CRESTWOOD
Mailing Address - State:IL
Mailing Address - Zip Code:60445-1123
Mailing Address - Country:US
Mailing Address - Phone:815-513-5268
Mailing Address - Fax:815-942-1851
Practice Address - Street 1:5553 127TH ST
Practice Address - Street 2:
Practice Address - City:CRESTWOOD
Practice Address - State:IL
Practice Address - Zip Code:60445-1123
Practice Address - Country:US
Practice Address - Phone:815-513-5268
Practice Address - Fax:815-942-1851
Is Sole Proprietor?:No
Enumeration Date:2016-10-10
Last Update Date:2016-10-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ILEH 016703237700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes237700000XSpeech, Language and Hearing Service ProvidersHearing Instrument Specialist