Provider Demographics
NPI:1306099122
Name:WALLS, EILEEN TARA (MS-CCC/SLP)
Entity type:Individual
Prefix:
First Name:EILEEN
Middle Name:TARA
Last Name:WALLS
Suffix:
Gender:F
Credentials:MS-CCC/SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:452 15TH ST
Mailing Address - Street 2:2L
Mailing Address - City:BROOKLYN
Mailing Address - State:NY
Mailing Address - Zip Code:11215-5777
Mailing Address - Country:US
Mailing Address - Phone:347-248-9121
Mailing Address - Fax:
Practice Address - Street 1:452 15TH ST
Practice Address - Street 2:2L
Practice Address - City:BROOKLYN
Practice Address - State:NY
Practice Address - Zip Code:11215-5777
Practice Address - Country:US
Practice Address - Phone:347-248-9121
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-10-23
Last Update Date:2008-10-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY007879235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist