Provider Demographics
NPI:1376791210
Name:WALSH, MARY M (LMSW)
Entity Type:Individual
Prefix:MS
First Name:MARY
Middle Name:M
Last Name:WALSH
Suffix:
Gender:F
Credentials:LMSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5023 41ST ST
Mailing Address - Street 2:
Mailing Address - City:SUNNYSIDE
Mailing Address - State:NY
Mailing Address - Zip Code:11104-3123
Mailing Address - Country:US
Mailing Address - Phone:212-560-6717
Mailing Address - Fax:212-244-2034
Practice Address - Street 1:344 W 36TH ST
Practice Address - Street 2:
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10018-7598
Practice Address - Country:US
Practice Address - Phone:212-560-6796
Practice Address - Fax:212-244-2034
Is Sole Proprietor?:Yes
Enumeration Date:2008-09-04
Last Update Date:2008-09-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY072830-11041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
NYW01882Medicaid
NYW01882Medicare UPIN