Provider Demographics
NPI:1407478506
Name:WALSH, EMILY
Entity Type:Individual
Prefix:
First Name:EMILY
Middle Name:
Last Name:WALSH
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6020 DREXEL LN APT 919
Mailing Address - Street 2:
Mailing Address - City:FORT MYERS
Mailing Address - State:FL
Mailing Address - Zip Code:33919-5254
Mailing Address - Country:US
Mailing Address - Phone:352-359-8835
Mailing Address - Fax:
Practice Address - Street 1:5050 TAMIAMI TRL N
Practice Address - Street 2:
Practice Address - City:NAPLES
Practice Address - State:FL
Practice Address - Zip Code:34103-2853
Practice Address - Country:US
Practice Address - Phone:239-351-0675
Practice Address - Fax:239-631-5295
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
FLRBT-20-117849106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician