Healthcare Provider Details

I. General information

NPI: 1821555368
Provider Name (Legal Business Name): JAMES QUENTIN WALSH LCSW
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

Provider Other Name: JAMES QUENTIN WALSH LCSW

II. Dates (important events)

Enumeration Date: 02/20/2019
Last Update Date: 02/20/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1850 W REPUBLIC RD
SPRINGFIELD MO
65807-5730
US

IV. Provider business mailing address

1850 W REPUBLIC RD
SPRINGFIELD MO
65807-5730
US

V. Phone/Fax

Practice location:
  • Phone: 844-501-8387
  • Fax: 417-891-4981
Mailing address:
  • Phone: 844-501-8387
  • Fax: 417-891-4981

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number2018012286
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: