Provider Demographics
NPI:1578649414
Name:WALSH, BART (LCSW)
Entity Type:Individual
Prefix:MR
First Name:BART
Middle Name:
Last Name:WALSH
Suffix:
Gender:M
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1306 SW BERTHA BLVD
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97219-2039
Mailing Address - Country:US
Mailing Address - Phone:503-293-1811
Mailing Address - Fax:
Practice Address - Street 1:2800 N. VANCOUVER AVE
Practice Address - Street 2:SUITE 118
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97227-1634
Practice Address - Country:US
Practice Address - Phone:503-249-8851
Practice Address - Fax:503-282-3409
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-31
Last Update Date:2023-10-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR13591041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR133344Medicare ID - Type UnspecifiedMEDICARE PART B