=====================================================
General NPI Number Information
=====================================================
NPI Number | 1356419345
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | KEVIN MICHAEL WALSH LCSW
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 11/30/2006
-----------------------------------------------------
Last Update Date | 07/08/2007
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 41-51 EAST 11TH STREET, 4TH FLOOR
-----------------------------------------------------
City | NEW YORK
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 10003
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 917-304-4889
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 241 SAINT JAMES PL # 1
-----------------------------------------------------
City | BROOKLYN
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 11238-2710
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 917-304-4889
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 1041C0700X
-----------------------------------------------------
Taxonomy Name | Clinical Social Worker
-----------------------------------------------------
License Number | 070136-1
-----------------------------------------------------
License Number State | NY
-----------------------------------------------------