Provider Demographics
NPI:1356419345
Name:WALSH, KEVIN MICHAEL (LCSW)
Entity type:Individual
Prefix:MR
First Name:KEVIN
Middle Name:MICHAEL
Last Name:WALSH
Suffix:
Gender:M
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:241 SAINT JAMES PL # 1
Mailing Address - Street 2:
Mailing Address - City:BROOKLYN
Mailing Address - State:NY
Mailing Address - Zip Code:11238-2710
Mailing Address - Country:US
Mailing Address - Phone:917-304-4889
Mailing Address - Fax:
Practice Address - Street 1:41-51 EAST 11TH STREET, 4TH FLOOR
Practice Address - Street 2:
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10003
Practice Address - Country:US
Practice Address - Phone:917-304-4889
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-30
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY070136-11041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
NYN532K1Medicare ID - Type UnspecifiedMEDICARE PROVIDER NUMBER