Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 225XP0019X | Occupational Therapist - Physical Rehabilitation | 056003469 | IL |
NPI | 1134538028 |
---|---|
Provider Name | Molly Walter |
First Address | Fairbury, IL 61739-1614 |
Second Address | Fairbury, IL 61739-1614 |
Gender | F |
NPI Entity type | Individual |
Is Sole Proprietor | Yes |
Is Organization Subpart | N/A |
Enumeration Date | 05/08/2014 |
Last Update Date | 05/08/2014 |