Provider Demographics
NPI:1851615447
Name:WALSH, GAIL (LMT)
Entity Type:Individual
Prefix:
First Name:GAIL
Middle Name:
Last Name:WALSH
Suffix:
Gender:F
Credentials:LMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4716 KITTY HAWK CIR
Mailing Address - Street 2:
Mailing Address - City:GULF BREEZE
Mailing Address - State:FL
Mailing Address - Zip Code:32563-9233
Mailing Address - Country:US
Mailing Address - Phone:850-261-5678
Mailing Address - Fax:
Practice Address - Street 1:1171 GULF BREEZE PKWY
Practice Address - Street 2:
Practice Address - City:GULF BREEZE
Practice Address - State:FL
Practice Address - Zip Code:32561-4835
Practice Address - Country:US
Practice Address - Phone:850-261-5678
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-03-25
Last Update Date:2010-03-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLMA#31796225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLMA#31796OtherFLORIDA STATE MASSAGE LICENSE NUMBER