Provider Demographics
NPI:1366028284
Name:WALSH, ANDREW R
Entity Type:Individual
Prefix:
First Name:ANDREW
Middle Name:R
Last Name:WALSH
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1333 S MAYFLOWER AVE STE 220
Mailing Address - Street 2:
Mailing Address - City:MONROVIA
Mailing Address - State:CA
Mailing Address - Zip Code:91016-5239
Mailing Address - Country:US
Mailing Address - Phone:818-241-6780
Mailing Address - Fax:888-588-2752
Practice Address - Street 1:24 ALBION RD STE 320
Practice Address - Street 2:
Practice Address - City:LINCOLN
Practice Address - State:RI
Practice Address - Zip Code:02865-3744
Practice Address - Country:US
Practice Address - Phone:855-295-3276
Practice Address - Fax:888-588-2752
Is Sole Proprietor?:No
Enumeration Date:2021-03-22
Last Update Date:2024-03-04
Deactivation Date:2023-09-25
Deactivation Code:
Reactivation Date:2023-11-02
Provider Licenses
StateLicense IDTaxonomies
RILBA00395103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA110026265EMedicaid