Healthcare Provider Details

I. General information

NPI: 1174908792
Provider Name (Legal Business Name): SHELLEY SUE WALSH
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/24/2015
Last Update Date: 07/24/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

16844 SAINT CLAIR AVE
EAST LIVERPOOL OH
43920-4277
US

IV. Provider business mailing address

1265 BOARDMAN CANFIELD RD
BOARDMAN OH
44512-4004
US

V. Phone/Fax

Practice location:
  • Phone: 330-386-6500
  • Fax: 330-386-1277
Mailing address:
  • Phone: 330-758-9400
  • Fax: 330-726-8676

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225700000X
TaxonomyMassage Therapist
License Number021091
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: