Provider Demographics
NPI:1790169738
Name:WALSH, JOHN DAVID (PMHNP-BC)
Entity Type:Individual
Prefix:
First Name:JOHN
Middle Name:DAVID
Last Name:WALSH
Suffix:
Gender:M
Credentials:PMHNP-BC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11 COLONEL HAZZARD RD
Mailing Address - Street 2:
Mailing Address - City:OKATIE
Mailing Address - State:SC
Mailing Address - Zip Code:29909-7003
Mailing Address - Country:US
Mailing Address - Phone:512-851-9260
Mailing Address - Fax:
Practice Address - Street 1:515 COURT ST
Practice Address - Street 2:
Practice Address - City:RENO
Practice Address - State:NV
Practice Address - Zip Code:89501-1710
Practice Address - Country:US
Practice Address - Phone:775-410-0189
Practice Address - Fax:775-339-0105
Is Sole Proprietor?:Yes
Enumeration Date:2015-07-18
Last Update Date:2024-04-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NV864972363LP0808X
TXAP128566363LP0808X
FLAPRN11025468363LP0808X
VT101.0136501363LP0808X
SCAPN.27723363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health