Provider Demographics
NPI:1407328735
Name:WALSH, CHERYL SUZANNNE (MFTT)
Entity Type:Individual
Prefix:
First Name:CHERYL
Middle Name:SUZANNNE
Last Name:WALSH
Suffix:
Gender:F
Credentials:MFTT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1402 PORTOBELLO DRIVE
Mailing Address - Street 2:
Mailing Address - City:PORT ORANGE
Mailing Address - State:FL
Mailing Address - Zip Code:32127
Mailing Address - Country:US
Mailing Address - Phone:386-566-3001
Mailing Address - Fax:
Practice Address - Street 1:533 N NOVA RD STE 204
Practice Address - Street 2:
Practice Address - City:ORMOND BEACH
Practice Address - State:FL
Practice Address - Zip Code:32174-4422
Practice Address - Country:US
Practice Address - Phone:386-898-5003
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-12-27
Last Update Date:2018-12-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health