Basic Information
| Provider Information | |||||||||
| NPI: | 1265509368 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | WALSH | ||||||||
| FirstName: | SUELLEN | ||||||||
| MiddleName: | |||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | PH.D. | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | WALSH ROTHER | ||||||||
| OtherFirstName: | SUELLEN | ||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | DR. | ||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | PH.D. | ||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 329 CONWAY ST | ||||||||
| Address2: | GREENFIELD HEALTH CENTER | ||||||||
| City: | GREENFIELD | ||||||||
| State: | MA | ||||||||
| PostalCode: | 013011521 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4137746301 | ||||||||
| FaxNumber: | 4137723395 | ||||||||
| Practice Location | |||||||||
| Address1: | 329 CONWAY ST | ||||||||
| Address2: | GREENFIELD HEALTH CENTER | ||||||||
| City: | GREENFIELD | ||||||||
| State: | MA | ||||||||
| PostalCode: | 013011521 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4137746301 | ||||||||
| FaxNumber: | 4137723395 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/30/2006 | ||||||||
| LastUpdateDate: | 01/07/2020 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
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| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 01/07/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 103TC2200X | 9499 | MA | N | Behavioral Health & Social Service Providers | Psychologist | Clinical Child & Adolescent | 103TF0000X | 9499 | MA | N | Behavioral Health & Social Service Providers | Psychologist | Family | 103TC0700X | 9499 | MA | Y | Behavioral Health & Social Service Providers | Psychologist | Clinical |
No ID Information.