Healthcare Provider Details

I. General information

NPI: 1508415001
Provider Name (Legal Business Name): COLLEEN MAE WALSH PT, DPT
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/06/2019
Last Update Date: 09/06/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5006 VETERANS HWY
HOLBROOK NY
11741-4514
US

IV. Provider business mailing address

23 JEFFERSON ST
EAST ISLIP NY
11730-1809
US

V. Phone/Fax

Practice location:
  • Phone: 631-416-6926
  • Fax:
Mailing address:
  • Phone: 631-495-6908
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2251S0007X
TaxonomySports Physical Therapist
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: