Provider Demographics
NPI:1629469515
Name:WALSH, PATRICIA
Entity Type:Individual
Prefix:
First Name:PATRICIA
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 1:380 S SAN DIMAS AVE
Mailing Address - Street 2:
Mailing Address - City:SAN DIMAS
Mailing Address - State:CA
Mailing Address - Zip Code:91773-4036
Mailing Address - Country:US
Mailing Address - Phone:626-804-0100
Mailing Address - Fax:626-963-9174
Practice Address - Street 1:380 S SAN DIMAS AVE
Practice Address - Street 2:
Practice Address - City:SAN DIMAS
Practice Address - State:CA
Practice Address - Zip Code:91773-4036
Practice Address - Country:US
Practice Address - Phone:626-804-0100
Practice Address - Fax:626-963-9174
Is Sole Proprietor?:Yes
Enumeration Date:2015-02-12
Last Update Date:2015-02-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA246091041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical