Provider Demographics
NPI:1902838675
Name:WALSH, KELLY (LISW)
Entity Type:Individual
Prefix:MS
First Name:KELLY
Middle Name:
Last Name:WALSH
Suffix:
Gender:F
Credentials:LISW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8479 S. MASON MONTGOMERY ROAD
Mailing Address - Street 2:SUITE 4
Mailing Address - City:MASON
Mailing Address - State:OH
Mailing Address - Zip Code:45040-4023
Mailing Address - Country:US
Mailing Address - Phone:513-443-2180
Mailing Address - Fax:513-725-1141
Practice Address - Street 1:8479 S. MASON MONTGOMERY ROAD
Practice Address - Street 2:SUITE 4
Practice Address - City:MASON
Practice Address - State:OH
Practice Address - Zip Code:45040-4023
Practice Address - Country:US
Practice Address - Phone:513-443-2180
Practice Address - Fax:513-725-1141
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-06
Last Update Date:2020-01-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
104100000X
OHI.18011291041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No104100000XBehavioral Health & Social Service ProvidersSocial Worker
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0364235Medicaid
KY184607OtherMEDICARE GROUP NUMBER
KY610661458OtherFEDERAL TAX ID NUMBER