Provider Demographics
NPI:1750443578
Name:WALSH, MICHAEL J (MED)
Entity Type:Individual
Prefix:MR
First Name:MICHAEL
Middle Name:J
Last Name:WALSH
Suffix:
Gender:M
Credentials:MED
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:830 HARRISON AVE
Mailing Address - Street 2:SUITE 1400
Mailing Address - City:BOSTON
Mailing Address - State:MA
Mailing Address - Zip Code:02218
Mailing Address - Country:US
Mailing Address - Phone:617-414-1768
Mailing Address - Fax:
Practice Address - Street 1:830 HARRISON AVE
Practice Address - Street 2:SUITE 1400
Practice Address - City:BOSTON
Practice Address - State:MA
Practice Address - Zip Code:02218
Practice Address - Country:US
Practice Address - Phone:617-414-1768
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-12-15
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA1494235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA00467449OtherASHA CERTIFICATION