=====================================================
General NPI Number Information
=====================================================
NPI Number | 1215560818
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | MEGHAN WALSH PT PLLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 02/21/2020
-----------------------------------------------------
Last Update Date | 02/21/2020
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 38 S ETNA AVE STE B
-----------------------------------------------------
City | MONTAUK
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 11954-5424
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 917-676-5963
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | PO BOX 865
-----------------------------------------------------
City | MONTAUK
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 11954-0701
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 917-676-5963
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | MEGHAN ANN WALSH
-----------------------------------------------------
Credential | MSPT
-----------------------------------------------------
Telephone | 917-676-5963
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 261QP2000X
-----------------------------------------------------
Taxonomy Name | Physical Therapy Clinic/Center
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------