Provider Demographics
NPI:1427734193
Name:WALSH, MADISON (DPT)
Entity type:Individual
Prefix:
First Name:MADISON
Middle Name:
Last Name:WALSH
Suffix:
Gender:F
Credentials:DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:647 SPIRIT AIRPARK WEST DR STE 101
Mailing Address - Street 2:
Mailing Address - City:CHESTERFIELD
Mailing Address - State:MO
Mailing Address - Zip Code:63005-1032
Mailing Address - Country:US
Mailing Address - Phone:636-206-4225
Mailing Address - Fax:
Practice Address - Street 1:754 LUETKENHAUS BLVD
Practice Address - Street 2:
Practice Address - City:WENTZVILLE
Practice Address - State:MO
Practice Address - Zip Code:63385-3515
Practice Address - Country:US
Practice Address - Phone:636-445-5001
Practice Address - Fax:636-887-0030
Is Sole Proprietor?:No
Enumeration Date:2023-06-26
Last Update Date:2023-08-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2023024735225100000X
MO2023033164225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist