Provider Demographics
NPI:1104634674
Name:WALSH, OLIVIA ANNE (PSYD)
Entity type:Individual
Prefix:
First Name:OLIVIA
Middle Name:ANNE
Last Name:WALSH
Suffix:
Gender:F
Credentials:PSYD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:428 SAGAMORE AVE
Mailing Address - Street 2:
Mailing Address - City:EAST WILLISTON
Mailing Address - State:NY
Mailing Address - Zip Code:11596-2440
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:6851 JERICHO TPKE STE 125
Practice Address - Street 2:
Practice Address - City:SYOSSET
Practice Address - State:NY
Practice Address - Zip Code:11791-4454
Practice Address - Country:US
Practice Address - Phone:516-780-0111
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-12-30
Last Update Date:2024-12-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYP133044103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical