MEDICARE: CHERYL SUZANNNE WALSH MFTT

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	101YM0800X	Mental Health Counselor

General Provider Information

NPI Number	:	1407328735
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	CHERYL SUZANNNE WALSH MFTT

Provider Business Mailing Address
First Line	:	1402 PORTOBELLO DRIVE
Second Line	:
City	:	PORT ORANGE
State	:	FL
Zip	:	32127
Country	:	US
Telephone Number	:	386-566-3001
Fax Number	:

Provider Business Practice Location Address
First Line	:	533 N NOVA RD STE 204
Second Line	:
City	:	ORMOND BEACH
State	:	FL
Zip	:	32174-4422
Country	:	US
Telephone Number	:	386-898-5003
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	12/27/2018
Last Update Date	:	12/27/2018

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