Healthcare Provider Details

I. General information

NPI: 1750755864
Provider Name (Legal Business Name): MYA NEALIE WALSH LCSW
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/01/2015
Last Update Date: 11/12/2024
Certification Date: 11/12/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

195 W DAVIS ST APT 331
DALLAS TX
75208-4429
US

IV. Provider business mailing address

315 S COLLEGE RD SUITE 100
LAFAYETTE LA
70503-3212
US

V. Phone/Fax

Practice location:
  • Phone: 678-596-1619
  • Fax:
Mailing address:
  • Phone: 337-205-6073
  • Fax: 337-264-9282

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101Y00000X
TaxonomyCounselor
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License NumberCSW009138
License Number StateGA
# 3
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number67690
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: