Provider Demographics
NPI:1285698274
Name:WALSH, MARY BETH (PT)
Entity type:Individual
Prefix:
First Name:MARY BETH
Middle Name:
Last Name:WALSH
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
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Mailing Address - Street 1:147 MILK ST
Mailing Address - Street 2:PROVIDER ENROLLMENT 9TH FLOOR
Mailing Address - City:BOSTON
Mailing Address - State:MA
Mailing Address - Zip Code:02109-4806
Mailing Address - Country:US
Mailing Address - Phone:617-559-8051
Mailing Address - Fax:
Practice Address - Street 1:133 BROOKLINE AVE
Practice Address - Street 2:
Practice Address - City:BOSTON
Practice Address - State:MA
Practice Address - Zip Code:02215-3904
Practice Address - Country:US
Practice Address - Phone:617-421-1347
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-04-14
Last Update Date:2009-04-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA12060225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA0020743OtherNEIGHBORHOOD HEALTH PLAN
MA0331261Medicaid
MA908025OtherTUFTS HEALTH PLAN
MAB425OtherHARVARD PILGRIM
MAY67651OtherBLUE CROSS
MAB501027OtherCIGNA
MAB501027OtherCIGNA