Provider Demographics
NPI:1174908792
Name:WALSH, SHELLEY SUE
Entity type:Individual
Prefix:
First Name:SHELLEY
Middle Name:SUE
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 1:1265 BOARDMAN CANFIELD RD
Mailing Address - Street 2:
Mailing Address - City:BOARDMAN
Mailing Address - State:OH
Mailing Address - Zip Code:44512-4004
Mailing Address - Country:US
Mailing Address - Phone:330-758-9400
Mailing Address - Fax:330-726-8676
Practice Address - Street 1:16844 SAINT CLAIR AVE
Practice Address - Street 2:
Practice Address - City:EAST LIVERPOOL
Practice Address - State:OH
Practice Address - Zip Code:43920-4277
Practice Address - Country:US
Practice Address - Phone:330-386-6500
Practice Address - Fax:330-386-1277
Is Sole Proprietor?:No
Enumeration Date:2015-07-24
Last Update Date:2015-07-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH021091225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist