Provider Demographics
NPI:1639662612
Name:WALCOTT, EMILY (CTRS, ATRIC)
Entity type:Individual
Prefix:
First Name:EMILY
Middle Name:
Last Name:WALCOTT
Suffix:
Gender:F
Credentials:CTRS, ATRIC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 1053
Mailing Address - Street 2:
Mailing Address - City:ADA
Mailing Address - State:MI
Mailing Address - Zip Code:49301-1053
Mailing Address - Country:US
Mailing Address - Phone:616-828-5492
Mailing Address - Fax:855-207-3270
Practice Address - Street 1:561 PARKSIDE AVE NW
Practice Address - Street 2:
Practice Address - City:GRAND RAPIDS
Practice Address - State:MI
Practice Address - Zip Code:49534-3410
Practice Address - Country:US
Practice Address - Phone:616-828-5492
Practice Address - Fax:855-207-3270
Is Sole Proprietor?:No
Enumeration Date:2018-06-13
Last Update Date:2018-06-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI225800000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225800000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersRecreation Therapist