Provider Demographics
NPI:1376023317
Name:WALSH, BRIAN P (MHC)
Entity type:Individual
Prefix:
First Name:BRIAN
Middle Name:P
Last Name:WALSH
Suffix:
Gender:M
Credentials:MHC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:279 SW BRIDGEPORT DR
Mailing Address - Street 2:
Mailing Address - City:PORT SAINT LUCIE
Mailing Address - State:FL
Mailing Address - Zip Code:34953-7112
Mailing Address - Country:US
Mailing Address - Phone:561-301-2616
Mailing Address - Fax:772-242-1296
Practice Address - Street 1:279 SW BRIDGEPORT DR
Practice Address - Street 2:
Practice Address - City:PORT SAINT LUCIE
Practice Address - State:FL
Practice Address - Zip Code:34953-7112
Practice Address - Country:US
Practice Address - Phone:561-301-2616
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-08-20
Last Update Date:2024-10-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL22047101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health