Provider Demographics
NPI:1417565987
Name:WALSH, ANTHONY T
Entity Type:Individual
Prefix:
First Name:ANTHONY
Middle Name:T
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 1:576 BROADHOLLOW RD
Mailing Address - Street 2:
Mailing Address - City:MELVILLE
Mailing Address - State:NY
Mailing Address - Zip Code:11747-5002
Mailing Address - Country:US
Mailing Address - Phone:631-359-5859
Mailing Address - Fax:
Practice Address - Street 1:85 S MAPLE AVE STE 1
Practice Address - Street 2:
Practice Address - City:RIDGEWOOD
Practice Address - State:NJ
Practice Address - Zip Code:07450-4500
Practice Address - Country:US
Practice Address - Phone:201-857-5396
Practice Address - Fax:201-857-5398
Is Sole Proprietor?:No
Enumeration Date:2020-07-21
Last Update Date:2020-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ40QA01925400225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist