Provider Demographics
NPI:1235369331
Name:WALSH, MARISA LYN (OTR/L)
Entity Type:Individual
Prefix:
First Name:MARISA
Middle Name:LYN
Last Name:WALSH
Suffix:
Gender:F
Credentials:OTR/L
Other - Prefix:
Other - First Name:MARISA
Other - Middle Name:LYN
Other - Last Name:JOSEPH
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:OTR/L
Mailing Address - Street 1:2117 COMMODORE CT
Mailing Address - Street 2:
Mailing Address - City:VIRGINIA BEACH
Mailing Address - State:VA
Mailing Address - Zip Code:23454-2802
Mailing Address - Country:US
Mailing Address - Phone:760-623-9197
Mailing Address - Fax:
Practice Address - Street 1:818 NEWTOWN RD
Practice Address - Street 2:
Practice Address - City:VIRGINIA BEACH
Practice Address - State:VA
Practice Address - Zip Code:23462-1116
Practice Address - Country:US
Practice Address - Phone:757-473-8016
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-07-23
Last Update Date:2015-06-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL056.007910225X00000X
CA13388225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist