Provider Demographics
NPI:1689253494
Name:WALSH, MEGAN CHRISTINE
Entity Type:Individual
Prefix:
First Name:MEGAN
Middle Name:CHRISTINE
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 1:9403 MANSFIELD RD
Mailing Address - Street 2:
Mailing Address - City:SHREVEPORT
Mailing Address - State:LA
Mailing Address - Zip Code:71118-3815
Mailing Address - Country:US
Mailing Address - Phone:318-861-8938
Mailing Address - Fax:
Practice Address - Street 1:9403 MANSFIELD RD
Practice Address - Street 2:
Practice Address - City:SHREVEPORT
Practice Address - State:LA
Practice Address - Zip Code:71118-3815
Practice Address - Country:US
Practice Address - Phone:318-861-8938
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-04-07
Last Update Date:2023-10-13
Deactivation Date:2023-10-10
Deactivation Code:
Reactivation Date:2023-10-13
Provider Licenses
StateLicense IDTaxonomies
LAR-11672106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician