Healthcare Provider Details

I. General information

NPI: 1720466774
Provider Name (Legal Business Name): JOSEPH WALSH JR. CASAC-T
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/11/2015
Last Update Date: 05/11/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

396 BROADWAY
MONTICELLO NY
12701-1157
US

IV. Provider business mailing address

396 BROADWAY
MONTICELLO NY
12701-1157
US

V. Phone/Fax

Practice location:
  • Phone: 845-794-8080
  • Fax: 845-794-8343
Mailing address:
  • Phone: 845-794-8080
  • Fax: 845-794-8343

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number27199
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: