Provider Demographics
NPI:1295923696
Name:WALSH, CAROL MARIE (RDLD)
Entity type:Individual
Prefix:MRS
First Name:CAROL
Middle Name:MARIE
Last Name:WALSH
Suffix:
Gender:F
Credentials:RDLD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4887 SOUTHIDGE PARK DRIVE
Mailing Address - Street 2:
Mailing Address - City:ST LOUIS
Mailing Address - State:MO
Mailing Address - Zip Code:63129-1773
Mailing Address - Country:US
Mailing Address - Phone:314-487-8413
Mailing Address - Fax:
Practice Address - Street 1:4887 SOUTHIDGE PARK DRIVE
Practice Address - Street 2:
Practice Address - City:ST LOUIS
Practice Address - State:MO
Practice Address - Zip Code:63129-1773
Practice Address - Country:US
Practice Address - Phone:314-487-8413
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-10-10
Last Update Date:2007-10-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO690853133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered