Provider Demographics
NPI:1184891038
Name:WALSH, MICHELLE A (PHD, LICSW)
Entity type:Individual
Prefix:MS
First Name:MICHELLE
Middle Name:A
Last Name:WALSH
Suffix:
Gender:F
Credentials:PHD, LICSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:21 OVERLOOK RIDGE TER
Mailing Address - Street 2:UNIT 515
Mailing Address - City:REVERE
Mailing Address - State:MA
Mailing Address - Zip Code:02151-1190
Mailing Address - Country:US
Mailing Address - Phone:617-767-7933
Mailing Address - Fax:
Practice Address - Street 1:27 CONGRESS ST
Practice Address - Street 2:SUITE 205-23
Practice Address - City:SALEM
Practice Address - State:MA
Practice Address - Zip Code:01970-7309
Practice Address - Country:US
Practice Address - Phone:617-767-7933
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-05-09
Last Update Date:2014-09-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA10259371041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA706111OtherTUFTS
MAPO7905OtherBCBS