Provider Demographics
NPI:1497422539
Name:WALSH, JODI
Entity Type:Individual
Prefix:
First Name:JODI
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 1:2003 SEVILLE ST
Mailing Address - Street 2:
Mailing Address - City:MARGATE
Mailing Address - State:FL
Mailing Address - Zip Code:33063-2473
Mailing Address - Country:US
Mailing Address - Phone:954-805-5860
Mailing Address - Fax:
Practice Address - Street 1:141 PARKER ST STE 306
Practice Address - Street 2:
Practice Address - City:MAYNARD
Practice Address - State:MA
Practice Address - Zip Code:01754-2180
Practice Address - Country:US
Practice Address - Phone:866-991-2103
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-08-26
Last Update Date:2023-05-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLSW15020OtherSTATE LICENSING BOARD
CA113437OtherSTATE LICENSING BOARD