Provider Demographics
NPI:1992963565
Name:WALSH, ANGELIQUE M (MA)
Entity type:Individual
Prefix:MS
First Name:ANGELIQUE
Middle Name:M
Last Name:WALSH
Suffix:
Gender:F
Credentials:MA
Other - Prefix:MS
Other - First Name:ANGELIQUE
Other - Middle Name:M
Other - Last Name:CHACON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:428 SW AKRON AVE
Mailing Address - Street 2:
Mailing Address - City:STUART
Mailing Address - State:FL
Mailing Address - Zip Code:34994-2951
Mailing Address - Country:US
Mailing Address - Phone:772-475-3350
Mailing Address - Fax:
Practice Address - Street 1:1887 SE PORT ST LUCIE BLVD
Practice Address - Street 2:
Practice Address - City:PORT ST LUCIE
Practice Address - State:FL
Practice Address - Zip Code:34952-5530
Practice Address - Country:US
Practice Address - Phone:772-475-3350
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-05-29
Last Update Date:2024-10-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL021528900Medicaid