Provider Demographics
NPI:1558726349
Name:WALSH, KATHERINE
Entity Type:Individual
Prefix:
First Name:KATHERINE
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 1:21 MALVERN LN
Mailing Address - Street 2:
Mailing Address - City:STONY BROOK
Mailing Address - State:NY
Mailing Address - Zip Code:11790-2832
Mailing Address - Country:US
Mailing Address - Phone:631-806-5339
Mailing Address - Fax:
Practice Address - Street 1:15 HORSEBLOCK PL
Practice Address - Street 2:
Practice Address - City:FARMINGVILLE
Practice Address - State:NY
Practice Address - Zip Code:11738-1204
Practice Address - Country:US
Practice Address - Phone:631-854-2552
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-12-21
Last Update Date:2024-04-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY088246-1104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker