Provider Demographics
NPI:1265509368
Name:WALSH, SUELLEN (PHD)
Entity Type:Individual
Prefix:DR
First Name:SUELLEN
Middle Name:
Last Name:WALSH
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:DR
Other - First Name:SUELLEN
Other - Middle Name:
Other - Last Name:WALSH ROTHER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PHD
Mailing Address - Street 1:329 CONWAY ST
Mailing Address - Street 2:GREENFIELD HEALTH CENTER
Mailing Address - City:GREENFIELD
Mailing Address - State:MA
Mailing Address - Zip Code:01301-1521
Mailing Address - Country:US
Mailing Address - Phone:413-774-6301
Mailing Address - Fax:413-772-3395
Practice Address - Street 1:329 CONWAY ST
Practice Address - Street 2:GREENFIELD HEALTH CENTER
Practice Address - City:GREENFIELD
Practice Address - State:MA
Practice Address - Zip Code:01301-1521
Practice Address - Country:US
Practice Address - Phone:413-774-6301
Practice Address - Fax:413-772-3395
Is Sole Proprietor?:No
Enumeration Date:2006-11-30
Last Update Date:2020-01-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA9499103TC2200X, 103TF0000X, 103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
No103TC2200XBehavioral Health & Social Service ProvidersPsychologistClinical Child & Adolescent
No103TF0000XBehavioral Health & Social Service ProvidersPsychologistFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
MAS400126481Medicare PIN
MA0027320Medicare PIN