Provider Demographics
NPI:1992114805
Name:WALSH, LAURIE (BS,)
Entity type:Individual
Prefix:MRS
First Name:LAURIE
Middle Name:
Last Name:WALSH
Suffix:
Gender:F
Credentials:BS,
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:312 E CHERRY COVE LN
Mailing Address - Street 2:
Mailing Address - City:ROUND LAKE BEACH
Mailing Address - State:IL
Mailing Address - Zip Code:60073-4805
Mailing Address - Country:US
Mailing Address - Phone:847-445-8615
Mailing Address - Fax:
Practice Address - Street 1:312 E CHERRY COVE LN
Practice Address - Street 2:
Practice Address - City:ROUND LAKE BEACH
Practice Address - State:IL
Practice Address - Zip Code:60073-4805
Practice Address - Country:US
Practice Address - Phone:847-445-8615
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-08-05
Last Update Date:2014-08-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL227011150225700000X
WI5079146225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist