Healthcare Provider Details

I. General information

NPI: 1093262578
Provider Name (Legal Business Name): CATHY WALLS PT
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/01/2016
Last Update Date: 09/01/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

945 N. 12TH ST
MILWAUKEE WI
53201
US

IV. Provider business mailing address

9505 W RUBY AVE
WAUWATOSA WI
53225-4813
US

V. Phone/Fax

Practice location:
  • Phone: 414-219-7776
  • Fax: 414-219-7775
Mailing address:
  • Phone: 414-520-2279
  • Fax: 414-219-7775

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2251S0007X
TaxonomySports Physical Therapist
License Number10604-24
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: