Provider Demographics
NPI:1124591359
Name:WALSH, KATHLEEN (MA, LPC)
Entity Type:Individual
Prefix:
First Name:KATHLEEN
Middle Name:
Last Name:WALSH
Suffix:
Gender:F
Credentials:MA, LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:165 KNEELAND RD
Mailing Address - Street 2:
Mailing Address - City:NEW HAVEN
Mailing Address - State:CT
Mailing Address - Zip Code:06512-5010
Mailing Address - Country:US
Mailing Address - Phone:781-606-2900
Mailing Address - Fax:
Practice Address - Street 1:1092 MAIN ST
Practice Address - Street 2:
Practice Address - City:BRANFORD
Practice Address - State:CT
Practice Address - Zip Code:06405-3716
Practice Address - Country:US
Practice Address - Phone:203-433-4579
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-01-10
Last Update Date:2019-01-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional