Healthcare Provider Details

I. General information

NPI: 1740299544
Provider Name (Legal Business Name): RICHARD G. WALSH PH.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/08/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2120 THIBODO COURT SUITE 230
VISTA CA
92083
US

IV. Provider business mailing address

1801 AVENIDA MIMOSA
ENCINITAS CA
92024-7121
US

V. Phone/Fax

Practice location:
  • Phone: 858-279-1223
  • Fax: 760-597-4880
Mailing address:
  • Phone: 760-436-2973
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License NumberMFC18120
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: