Provider Demographics
NPI:1114903564
Name:WALSH, MARY M (OTR/L, CHT)
Entity Type:Individual
Prefix:
First Name:MARY
Middle Name:M
Last Name:WALSH
Suffix:
Gender:F
Credentials:OTR/L, CHT
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 87089
Mailing Address - Street 2:
Mailing Address - City:FAYETTEVILLE
Mailing Address - State:NC
Mailing Address - Zip Code:28304-7089
Mailing Address - Country:US
Mailing Address - Phone:910-484-4653
Mailing Address - Fax:910-483-9256
Practice Address - Street 1:1991 FORDHAM DR STE 102
Practice Address - Street 2:
Practice Address - City:FAYETTEVILLE
Practice Address - State:NC
Practice Address - Zip Code:28304-3774
Practice Address - Country:US
Practice Address - Phone:910-484-4653
Practice Address - Fax:910-483-9256
Is Sole Proprietor?:No
Enumeration Date:2005-12-19
Last Update Date:2020-07-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAOT006212225XH1200X
NC0234225XH1200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225XH1200XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational TherapistHand
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC2510503AMedicare PIN