Provider Demographics
NPI:1447544226
Name:WALSTROM, AMANDA N (PT)
Entity type:Individual
Prefix:
First Name:AMANDA
Middle Name:N
Last Name:WALSTROM
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:623 INDEPENDENCE AVE
Mailing Address - Street 2:
Mailing Address - City:ELBURN
Mailing Address - State:IL
Mailing Address - Zip Code:60119-9470
Mailing Address - Country:US
Mailing Address - Phone:630-251-4498
Mailing Address - Fax:
Practice Address - Street 1:623 INDEPENDENCE AVE
Practice Address - Street 2:
Practice Address - City:ELBURN
Practice Address - State:IL
Practice Address - Zip Code:60119-9470
Practice Address - Country:US
Practice Address - Phone:630-251-4498
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-06-08
Last Update Date:2011-06-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL070017338225100000X
COPTL-9552225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist