Healthcare Provider Details

I. General information

NPI: 1144828369
Provider Name (Legal Business Name): SHANE MICHAEL WALSH OTR/L
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/09/2020
Last Update Date: 10/09/2020
Certification Date: 10/09/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

24 TREMONT ST
BRIGHTON MA
02135-2407
US

IV. Provider business mailing address

15 BELMONT AVE
HAVERHILL MA
01830-6601
US

V. Phone/Fax

Practice location:
  • Phone: 908-565-3281
  • Fax:
Mailing address:
  • Phone: 978-314-9328
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225XP0200X
TaxonomyPediatric Occupational Therapist
License Number13531
License Number StateMA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: