Provider Demographics
NPI:1073028734
Name:AUDRA WALSH, PHD, LLC
Entity type:Organization
Organization Name:AUDRA WALSH, PHD, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:LICENSED PSYCHOLOGIST
Authorized Official - Prefix:DR
Authorized Official - First Name:AUDRA
Authorized Official - Middle Name:
Authorized Official - Last Name:WALSH
Authorized Official - Suffix:
Authorized Official - Credentials:PHD
Authorized Official - Phone:727-599-3624
Mailing Address - Street 1:1039 PARK ST N
Mailing Address - Street 2:
Mailing Address - City:ST PETERSBURG
Mailing Address - State:FL
Mailing Address - Zip Code:33710-4317
Mailing Address - Country:US
Mailing Address - Phone:727-599-3624
Mailing Address - Fax:
Practice Address - Street 1:1039 PARK ST N
Practice Address - Street 2:
Practice Address - City:ST PETERSBURG
Practice Address - State:FL
Practice Address - Zip Code:33710-4317
Practice Address - Country:US
Practice Address - Phone:727-599-3624
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-12-04
Last Update Date:2017-12-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPY9751103TC2200X
FLPY9148103TC2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103TC2200XBehavioral Health & Social Service ProvidersPsychologistClinical Child & AdolescentGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL1205249752Medicaid
FL1477710416Medicaid