Healthcare Provider Details

I. General information

NPI: 1821877010
Provider Name (Legal Business Name): SUSAN SARITA WALSH
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/26/2023
Last Update Date: 03/19/2025
Certification Date: 03/17/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3024 E EMPIRE ST STE A
BLOOMINGTON IL
61704-5402
US

IV. Provider business mailing address

611 W PARK FAPC
URBANA IL
61602-1060
US

V. Phone/Fax

Practice location:
  • Phone: 309-556-7800
  • Fax:
Mailing address:
  • Phone: 309-556-7800
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License Number209028319
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: