Provider Demographics
NPI:1205891546
Name:WALSH, CHARLES R JR (LCSW)
Entity type:Individual
Prefix:
First Name:CHARLES
Middle Name:R
Last Name:WALSH
Suffix:JR
Gender:M
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9228 GEORGE WASHINGTON MEMORIAL HWY
Mailing Address - Street 2:
Mailing Address - City:GLOUCESTER
Mailing Address - State:VA
Mailing Address - Zip Code:23061-4162
Mailing Address - Country:US
Mailing Address - Phone:804-693-5068
Mailing Address - Fax:804-639-7407
Practice Address - Street 1:9228 GEORGE WASHINGTON MEMORIAL HWY
Practice Address - Street 2:
Practice Address - City:GLOUCESTER
Practice Address - State:VA
Practice Address - Zip Code:23061-4162
Practice Address - Country:US
Practice Address - Phone:804-693-5068
Practice Address - Fax:804-639-7407
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-04-19
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA09040019821041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA250210Medicaid
VAO85330Medicaid
VA250212OtherHEALTHKEEPERS
VA250210OtherANTHEM
VA250212OtherANTHEM
VA250210OtherHEALTHKEEPERS
VA250212Medicaid
VA250212Medicaid
VA250210Medicaid