Provider Demographics
NPI:1174003560
Name:WELSH, WALLIS ELYSE
Entity Type:Individual
Prefix:
First Name:WALLIS
Middle Name:ELYSE
Last Name:WELSH
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 1:50 WAVERLEY ST APT 2
Mailing Address - Street 2:
Mailing Address - City:BELMONT
Mailing Address - State:MA
Mailing Address - Zip Code:02478-1960
Mailing Address - Country:US
Mailing Address - Phone:330-209-5728
Mailing Address - Fax:
Practice Address - Street 1:12 HANCOCK CT
Practice Address - Street 2:
Practice Address - City:QUINCY
Practice Address - State:MA
Practice Address - Zip Code:02169-5210
Practice Address - Country:US
Practice Address - Phone:617-847-1950
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-08-15
Last Update Date:2018-08-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA16-183221700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes221700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersArt Therapist