Provider Demographics
NPI:1437652054
Name:WALSH, CRYSTAL (MASTERS)
Entity type:Individual
Prefix:
First Name:CRYSTAL
Middle Name:
Last Name:WALSH
Suffix:
Gender:F
Credentials:MASTERS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 190
Mailing Address - Street 2:
Mailing Address - City:BOYDTON
Mailing Address - State:VA
Mailing Address - Zip Code:23917-0190
Mailing Address - Country:US
Mailing Address - Phone:424-210-6201
Mailing Address - Fax:
Practice Address - Street 1:175 MAYFIELD DR
Practice Address - Street 2:
Practice Address - City:BOYDTON
Practice Address - State:VA
Practice Address - Zip Code:23917-2817
Practice Address - Country:US
Practice Address - Phone:424-210-6201
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-03-09
Last Update Date:2018-03-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0813000438103TS0200X
103TS0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TS0200XBehavioral Health & Social Service ProvidersPsychologistSchool
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA0813000438Medicaid