Provider Demographics
NPI:1962010868
Name:WALSH, CORY CHESTER
Entity Type:Individual
Prefix:
First Name:CORY
Middle Name:CHESTER
Last Name:WALSH
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1133 LOUISIANA AVE STE 208
Mailing Address - Street 2:
Mailing Address - City:WINTER PARK
Mailing Address - State:FL
Mailing Address - Zip Code:32789-2350
Mailing Address - Country:US
Mailing Address - Phone:321-325-0670
Mailing Address - Fax:
Practice Address - Street 1:1133 LOUISIANA AVE STE 208
Practice Address - Street 2:
Practice Address - City:WINTER PARK
Practice Address - State:FL
Practice Address - Zip Code:32789-2350
Practice Address - Country:US
Practice Address - Phone:321-325-0670
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-07-16
Last Update Date:2023-06-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLMH22315101YM0800X
FLIMT3354106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist