Provider Demographics
NPI:1396330585
Name:WALSH, KEVIN PATRICK
Entity type:Individual
Prefix:
First Name:KEVIN
Middle Name:PATRICK
Last Name:WALSH
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9240 FOUR MILE CREEK RD
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28277-9063
Mailing Address - Country:US
Mailing Address - Phone:704-773-2380
Mailing Address - Fax:
Practice Address - Street 1:825 E 2ND AVE
Practice Address - Street 2:
Practice Address - City:GASTONIA
Practice Address - State:NC
Practice Address - Zip Code:28054-4256
Practice Address - Country:US
Practice Address - Phone:704-854-9102
Practice Address - Fax:704-854-9913
Is Sole Proprietor?:Yes
Enumeration Date:2021-03-09
Last Update Date:2021-03-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCCADC-23323101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)Group - Multi-Specialty