Basic Information
| Provider Information | |||||||||
| NPI: | 1235369331 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | WALSH | ||||||||
| FirstName: | MARISA | ||||||||
| MiddleName: | LYN | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | OTR/L | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | JOSEPH | ||||||||
| OtherFirstName: | MARISA | ||||||||
| OtherMiddleName: | LYN | ||||||||
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| OtherCredential: | OTR/L | ||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 2117 COMMODORE CT | ||||||||
| Address2: | |||||||||
| City: | VIRGINIA BEACH | ||||||||
| State: | VA | ||||||||
| PostalCode: | 234542802 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7606239197 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 818 NEWTOWN RD | ||||||||
| Address2: | |||||||||
| City: | VIRGINIA BEACH | ||||||||
| State: | VA | ||||||||
| PostalCode: | 234621116 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7574738016 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/23/2009 | ||||||||
| LastUpdateDate: | 06/26/2015 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225X00000X | 056.007910 | IL | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Occupational Therapist | 225X00000X | 13388 | CA | N | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Occupational Therapist |
No ID Information.