Provider Demographics
NPI:1215446125
Name:WALSH, MARY BETH ANN
Entity type:Individual
Prefix:
First Name:MARY BETH
Middle Name:ANN
Last Name:WALSH
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:MARIBETH
Other - Middle Name:ANN
Other - Last Name:WALSH
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:1192 CAMELOT LN
Mailing Address - Street 2:
Mailing Address - City:LEMONT
Mailing Address - State:IL
Mailing Address - Zip Code:60439-8530
Mailing Address - Country:US
Mailing Address - Phone:630-863-0745
Mailing Address - Fax:
Practice Address - Street 1:348 55TH ST
Practice Address - Street 2:
Practice Address - City:CLARENDON HILLS
Practice Address - State:IL
Practice Address - Zip Code:60514-3015
Practice Address - Country:US
Practice Address - Phone:630-670-0901
Practice Address - Fax:630-654-4619
Is Sole Proprietor?:Yes
Enumeration Date:2017-09-22
Last Update Date:2017-09-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL146.002200235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist