Provider Demographics
NPI:1194049577
Name:WALSH, MAXINE
Entity type:Individual
Prefix:MRS
First Name:MAXINE
Middle Name:
Last Name:WALSH
Suffix:
Gender:F
Credentials:
Other - Prefix:MISS
Other - First Name:MAXINE
Other - Middle Name:
Other - Last Name:MOURA
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:OT
Mailing Address - Street 1:175 JEFFERSON ST
Mailing Address - Street 2:
Mailing Address - City:FAIRFIELD
Mailing Address - State:CT
Mailing Address - Zip Code:06825-1078
Mailing Address - Country:US
Mailing Address - Phone:203-365-6443
Mailing Address - Fax:203-396-1046
Practice Address - Street 1:175 JEFFERSON ST
Practice Address - Street 2:
Practice Address - City:FAIRFIELD
Practice Address - State:CT
Practice Address - Zip Code:06825-1078
Practice Address - Country:US
Practice Address - Phone:203-365-6443
Practice Address - Fax:203-396-1046
Is Sole Proprietor?:Yes
Enumeration Date:2010-03-15
Last Update Date:2010-03-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT001136225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist