Provider Demographics
NPI:1144828369
Name:WALSH, SHANE MICHAEL (OTR/L)
Entity type:Individual
Prefix:MR
First Name:SHANE
Middle Name:MICHAEL
Last Name:WALSH
Suffix:
Gender:M
Credentials:OTR/L
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:15 BELMONT AVE
Mailing Address - Street 2:
Mailing Address - City:HAVERHILL
Mailing Address - State:MA
Mailing Address - Zip Code:01830-6601
Mailing Address - Country:US
Mailing Address - Phone:978-314-9328
Mailing Address - Fax:
Practice Address - Street 1:24 TREMONT ST
Practice Address - Street 2:
Practice Address - City:BRIGHTON
Practice Address - State:MA
Practice Address - Zip Code:02135-2407
Practice Address - Country:US
Practice Address - Phone:908-565-3281
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-10-09
Last Update Date:2020-10-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA13531225XP0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225XP0200XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational TherapistPediatrics