Provider Demographics
NPI:1316095508
Name:WALSH, SUSAN MARIE (LICSW)
Entity type:Individual
Prefix:MS
First Name:SUSAN
Middle Name:MARIE
Last Name:WALSH
Suffix:
Gender:F
Credentials:LICSW
Other - Prefix:MS
Other - First Name:SUSAN
Other - Middle Name:MARIE
Other - Last Name:WALSH
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:LICSW
Mailing Address - Street 1:101 KAY ST
Mailing Address - Street 2:
Mailing Address - City:NEWPORT
Mailing Address - State:RI
Mailing Address - Zip Code:02840-2835
Mailing Address - Country:US
Mailing Address - Phone:401-846-4587
Mailing Address - Fax:401-846-4587
Practice Address - Street 1:42 SPRING ST
Practice Address - Street 2:SUITE 13
Practice Address - City:NEWPORT
Practice Address - State:RI
Practice Address - Zip Code:02840-2979
Practice Address - Country:US
Practice Address - Phone:401-842-0009
Practice Address - Fax:401-842-0059
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-06
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
RIISW00716101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional