Basic Information
| Provider Information | |||||||||
| NPI: | 1699922302 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | WALSH | ||||||||
| FirstName: | BRUCE | ||||||||
| MiddleName: | WAYNE | ||||||||
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| Mailing Information | |||||||||
| Address1: | 104 NEW STATESIDE DR | ||||||||
| Address2: | |||||||||
| City: | CHAPEL HILL | ||||||||
| State: | NC | ||||||||
| PostalCode: | 275161165 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9199422803 | ||||||||
| FaxNumber: | 9199422126 | ||||||||
| Practice Location | |||||||||
| Address1: | 355 C1 S. MADISON BLVD | ||||||||
| Address2: | |||||||||
| City: | ROXBORO | ||||||||
| State: | NC | ||||||||
| PostalCode: | 27573 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3365998366 | ||||||||
| FaxNumber: | 3363226168 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/25/2008 | ||||||||
| LastUpdateDate: | 08/25/2008 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101YA0400X | 1977 | NC | Y | Behavioral Health & Social Service Providers | Counselor | Addiction (Substance Use Disorder) |
No ID Information.