Provider Demographics
NPI:1841294899
Name:CLEARY, WALTER K (PT)
Entity type:Individual
Prefix:MR
First Name:WALTER
Middle Name:K
Last Name:CLEARY
Suffix:
Gender:M
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1480 18TH ST
Mailing Address - Street 2:
Mailing Address - City:CORBIN
Mailing Address - State:KY
Mailing Address - Zip Code:40701-2721
Mailing Address - Country:US
Mailing Address - Phone:606-528-0891
Mailing Address - Fax:606-528-3449
Practice Address - Street 1:1480 18TH ST
Practice Address - Street 2:
Practice Address - City:CORBIN
Practice Address - State:KY
Practice Address - Zip Code:40701-2721
Practice Address - Country:US
Practice Address - Phone:606-528-0870
Practice Address - Fax:606-528-3449
Is Sole Proprietor?:No
Enumeration Date:2005-06-08
Last Update Date:2008-01-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC1263225100000X
KY966225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY640224OtherUNITED HEALTHCARE
KY00000004875OtherANTHEM
KYR40148Medicare UPIN
KY00000004875OtherANTHEM