Provider Demographics
NPI:1487110219
Name:WALSH, ANN
Entity type:Individual
Prefix:
First Name:ANN
Middle Name:
Last Name:WALSH
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:900 RAND RD STE 300
Mailing Address - Street 2:
Mailing Address - City:DES PLAINES
Mailing Address - State:IL
Mailing Address - Zip Code:60016-2359
Mailing Address - Country:US
Mailing Address - Phone:847-324-3976
Mailing Address - Fax:847-929-1154
Practice Address - Street 1:720 FLORSHEIM DR
Practice Address - Street 2:
Practice Address - City:LIBERTYVILLE
Practice Address - State:IL
Practice Address - Zip Code:60048-3757
Practice Address - Country:US
Practice Address - Phone:847-247-4000
Practice Address - Fax:847-234-2090
Is Sole Proprietor?:No
Enumeration Date:2019-02-18
Last Update Date:2022-01-28
Deactivation Date:2021-07-28
Deactivation Code:
Reactivation Date:2021-08-11
Provider Licenses
StateLicense IDTaxonomies
ILRBT019-74946106S00000X
IL085-008629363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No106S00000XBehavioral Health & Social Service ProvidersBehavior Technician