Provider Demographics
NPI:1225754179
Name:WALSH, SHANNON
Entity Type:Individual
Prefix:
First Name:SHANNON
Middle Name:
Last Name:WALSH
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 1:1100 2ND PL SE APT 906
Mailing Address - Street 2:
Mailing Address - City:WASHINGTON
Mailing Address - State:DC
Mailing Address - Zip Code:20003-2566
Mailing Address - Country:US
Mailing Address - Phone:541-915-3363
Mailing Address - Fax:
Practice Address - Street 1:500 INDIANA AVE NW STE 1230
Practice Address - Street 2:
Practice Address - City:WASHINGTON
Practice Address - State:DC
Practice Address - Zip Code:20001-2131
Practice Address - Country:US
Practice Address - Phone:202-879-1974
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-10-12
Last Update Date:2023-06-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AL5104C1041C0700X
DCLC2000021141041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical