1770696940 NPI number — MS. PHYLLIS ANN WALSH LMSW ACSW

Table of content: MS. PHYLLIS ANN WALSH LMSW ACSW (NPI 1770696940)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1770696940 NPI number — MS. PHYLLIS ANN WALSH LMSW ACSW

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
WALSH
Provider First Name:
PHYLLIS ANN
Provider Middle Name:
Provider Name Prefix Text:
MS.
Provider Name Suffix Text:
Provider Credential Text:
LMSW ACSW
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1770696940
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
01/20/2009
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
429 PERCH POND ROAD
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
NINEVEH
Provider Business Mailing Address State Name:
NY
Provider Business Mailing Address Postal Code:
13813-1127
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
607-693-2682
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
81 E MAIN ST APT A
Provider Second Line Business Practice Location Address:
FAMILIES IN HARMONY
Provider Business Practice Location Address City Name:
AFTON
Provider Business Practice Location Address State Name:
NY
Provider Business Practice Location Address Postal Code:
13730-3203
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
607-639-2300
Provider Business Practice Location Address Fax Number:
607-693-2692
Provider Enumeration Date:
08/15/2006

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 1041C0700X , with the licence number:  072508 , registered in the state of NY ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)





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