Healthcare Provider Details

I. General information

NPI: 1548669773
Provider Name (Legal Business Name): CATHLEEN WALSH PTA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/13/2014
Last Update Date: 08/13/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4550 S CLYDE MORRIS BLVD STE D.
PORT ORANGE FL
32129-5294
US

IV. Provider business mailing address

3900 YORKTOWNE BLVD APT. 505
PORT ORANGE FL
32129-6008
US

V. Phone/Fax

Practice location:
  • Phone: 386-492-2986
  • Fax:
Mailing address:
  • Phone: 386-679-8816
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225200000X
TaxonomyPhysical Therapy Assistant
License Number22799
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: