Provider Demographics
NPI:1174248645
Name:WALSH, AUTUMN MARIE
Entity type:Individual
Prefix:
First Name:AUTUMN
Middle Name:MARIE
Last Name:WALSH
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2 LEHNER RD
Mailing Address - Street 2:
Mailing Address - City:SACO
Mailing Address - State:ME
Mailing Address - Zip Code:04072-1836
Mailing Address - Country:US
Mailing Address - Phone:207-300-2471
Mailing Address - Fax:207-692-0222
Practice Address - Street 1:2 LEHNER RD
Practice Address - Street 2:
Practice Address - City:SACO
Practice Address - State:ME
Practice Address - Zip Code:04072-1836
Practice Address - Country:US
Practice Address - Phone:207-300-2471
Practice Address - Fax:207-692-0222
Is Sole Proprietor?:No
Enumeration Date:2022-10-07
Last Update Date:2022-10-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MEADCA7814101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)