Provider Demographics
NPI:1962388629
Name:WALACH, ANT
Entity type:Individual
Prefix:
First Name:ANT
Middle Name:
Last Name:WALACH
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11128 HAMBORG RD
Mailing Address - Street 2:
Mailing Address - City:ROSCOE
Mailing Address - State:IL
Mailing Address - Zip Code:61073-9111
Mailing Address - Country:US
Mailing Address - Phone:510-590-6006
Mailing Address - Fax:
Practice Address - Street 1:6072 BRYNWOOD DR STE 205
Practice Address - Street 2:
Practice Address - City:ROCKFORD
Practice Address - State:IL
Practice Address - Zip Code:61114-5829
Practice Address - Country:US
Practice Address - Phone:815-846-0684
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2025-08-15
Last Update Date:2025-08-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health