Provider Demographics
NPI:1134271612
Name:WALSH, SUSAN HATTIE (LICSW)
Entity type:Individual
Prefix:
First Name:SUSAN
Middle Name:HATTIE
Last Name:WALSH
Suffix:
Gender:F
Credentials:LICSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:401 GILFORD AVE
Mailing Address - Street 2:P.O.BOX 7274
Mailing Address - City:GILFORD
Mailing Address - State:NH
Mailing Address - Zip Code:03249-7500
Mailing Address - Country:US
Mailing Address - Phone:603-528-1341
Mailing Address - Fax:603-528-2257
Practice Address - Street 1:401 GILFORD AVE
Practice Address - Street 2:
Practice Address - City:GILFORD
Practice Address - State:NH
Practice Address - Zip Code:03249-7500
Practice Address - Country:US
Practice Address - Phone:603-528-1341
Practice Address - Fax:603-528-2257
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-17
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NH5001041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
NH30006845Medicaid
NHWARE3252Medicare ID - Type Unspecified