MEDICARE: MR. GREGORY DAVID WALSH LICSW

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	1041C0700X	Clinical Social Worker	9379	MN
2	103TB0200X	Cognitive & Behavioral Psychologist

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier Issuer
1	6236362	OTHER	MEDICA-UBH
2	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
3	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1427089036
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MR. GREGORY DAVID WALSH LICSW

Provider Business Mailing Address
First Line	:	PO BOX 82
Second Line	:	VICTORIA MENTAL HEALTH SERVICES, LTD.
City	:	VICTORIA
State	:	MN
Zip	:	55386-0082
Country	:	US
Telephone Number	:	952-443-3970
Fax Number	:	952-368-3177

Provider Business Practice Location Address
First Line	:	1600 ARBORETUM BLVD
Second Line	:	SUITE # 211
City	:	VICTORIA
State	:	MN
Zip	:	55386-7705
Country	:	US
Telephone Number	:	952-443-3970
Fax Number	:	952-368-3177

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	07/05/2006
Last Update Date	:	08/11/2010

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