Provider Demographics
NPI:1124638481
Name:WALSH, SHANNON REBECCA
Entity type:Individual
Prefix:
First Name:SHANNON
Middle Name:REBECCA
Last Name:WALSH
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:79 FITZGERALD DR
Mailing Address - Street 2:
Mailing Address - City:EAST HARTFORD
Mailing Address - State:CT
Mailing Address - Zip Code:06118-2361
Mailing Address - Country:US
Mailing Address - Phone:860-682-5373
Mailing Address - Fax:
Practice Address - Street 1:10 N MAIN ST
Practice Address - Street 2:
Practice Address - City:BRISTOL
Practice Address - State:CT
Practice Address - Zip Code:06010-8122
Practice Address - Country:US
Practice Address - Phone:860-793-3500
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-08-03
Last Update Date:2020-08-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker