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General NPI Number Information
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NPI Number | 1285144931
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Entity Type | Individual
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Provider Name | SAMUEL F WALSTRUM PT, DPT, ATC
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Gender | Male
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Dates
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Enumeration Date | 10/09/2017
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Last Update Date | 08/04/2021
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Provider Practice Location Address
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Address Line | 1286 TRACIE DR
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City | LAKE ZURICH
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State | IL
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Zip | 60047-3342
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Country | US
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Telephone | 224-633-6405
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Fax |
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Provider Business Mailing Address
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Address Line | 1927 LINCOLN DR
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City | ANNAPOLIS
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State | MD
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Zip | 21401-4118
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Country | US
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Telephone |
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 2255A2300X
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Taxonomy Name | Athletic Trainer
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License Number |
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License Number State |
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Taxonomy #2
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Taxonomy Code | 225100000X
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Taxonomy Name | Physical Therapist
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License Number | 28560
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License Number State | MD
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