Provider Demographics
NPI:1396367413
Name:WALSH, KAITLIN SUZANNE (MSED)
Entity Type:Individual
Prefix:
First Name:KAITLIN
Middle Name:SUZANNE
Last Name:WALSH
Suffix:
Gender:F
Credentials:MSED
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1064 LASKIN RD STE 14C
Mailing Address - Street 2:
Mailing Address - City:VIRGINIA BEACH
Mailing Address - State:VA
Mailing Address - Zip Code:23451-6337
Mailing Address - Country:US
Mailing Address - Phone:757-817-2577
Mailing Address - Fax:
Practice Address - Street 1:1064 LASKIN RD STE 14C
Practice Address - Street 2:
Practice Address - City:VIRGINIA BEACH
Practice Address - State:VA
Practice Address - Zip Code:23451-6337
Practice Address - Country:US
Practice Address - Phone:757-817-2577
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-05-12
Last Update Date:2020-05-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0704011937101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health