Provider Demographics
NPI:1366777880
Name:WALSTROM KEHRWALD, ELIZABETH (AUD)
Entity type:Individual
Prefix:
First Name:ELIZABETH
Middle Name:
Last Name:WALSTROM KEHRWALD
Suffix:
Gender:F
Credentials:AUD
Other - Prefix:
Other - First Name:ELIZABETH
Other - Middle Name:
Other - Last Name:WALSTROM
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:AUD
Mailing Address - Street 1:4601 HERITAGE TRACE PARKWAY
Mailing Address - Street 2:
Mailing Address - City:FORT WORTH
Mailing Address - State:TX
Mailing Address - Zip Code:76244
Mailing Address - Country:US
Mailing Address - Phone:817-431-7985
Mailing Address - Fax:817-431-5031
Practice Address - Street 1:4601 HERITAGE TRACE PKWY
Practice Address - Street 2:
Practice Address - City:KELLER
Practice Address - State:TX
Practice Address - Zip Code:76244
Practice Address - Country:US
Practice Address - Phone:817-431-7985
Practice Address - Fax:817-431-5031
Is Sole Proprietor?:No
Enumeration Date:2009-10-16
Last Update Date:2014-10-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO570231H00000X, 231HA2400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes231H00000XSpeech, Language and Hearing Service ProvidersAudiologist
No231HA2400XSpeech, Language and Hearing Service ProvidersAudiologistAssistive Technology Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO570OtherAUDIOLOGY LICENSE
COCO306635Medicare Oscar/Certification