Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 101YP2500X | Professional Counselor | IL |
NPI | 1003879040 |
---|---|
Provider Name | Robert Walsh |
First Address | La Grange, IL 60525-2342 |
Second Address | Western Springs, IL 60558-1464 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 10/04/2006 |
Last Update Date | 08/07/2007 |